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Case Report

A Case of Cutaneous Purpureocillium lilacinum Infection Looking like Psoriasis

Abstract

Purpureocillium lilacinum is a saprophytic fungus with a ubiquitous environmental distribution, and it can be detected in soil samples and decaying materials worldwide. It has been reported as an emerging pathogen in both immunocompromised and immunocompetent patients, showing various cutaneous presentations. Herein, we report a case of a patient with a localized cutaneous P. lilacinum infection, which resembles the skin lesions of psoriasis. A 72-year-old female was presented with a peripherally spreading, well-demarcated, asymptomatic, scaly, erythematous patch on her forehead for several months. Histopathological examination showed pinkish septated fungal elements and mixed inflammatory and granulomatous infiltrates in the dermis. Furthermore, a fungal culture on potato dextrose agar showed gray, velvety colonies with light yellow background after being subcultured. Phialides with chains of oval conidia were observed on lactophenol cotton blue staining. The ITS region of rRNA gene sequence obtained from the colony was identical to that of Purpureocillium lilacinum. The lesion was resolved with oral itraconazole (200 mg/day) after four months of treatment.



Keywords



Cutaneous infection Psoriasis Purpureocillium lilacinum



INTRODUCTION

Purpureocillium lilacinum, which was previously known as Paecilomyces lilacinus, is a ubiquitous, saprobic filamentous fungus commonly isolated from soil, decaying vegetation, insects, nematodes, and laboratory air (as a contaminant)1. In recent studies, it has been reported as an emerging patho- gen in both immunocompetent and immunocompromised patients2, commonly causing ocular and subcutaneous infections3. Cutaneous P. lilacinum infections have various clinical manifestations, such as small erythematous papules, plaques with central umbilication, or hemorrhagic vesicles or ulcerations4. However, no standard antifungal treatment regimen has been established, so several systemic antifungal agents and surgical excision are used5,6. Herein, we encountered a rare case of cutaneous P. lilacinum infection, which resembles the skin lesions of psoriasis in a healthy immunocompetent patient.

CASE REPORT

A 72-year-old female was presented with a peripherally spreading, well-demarcated, asymptomatic, scaly, erythema- tous patch on her forehead for several months (Fig. 1A). The patient was not immunocompromised, and laboratory test results, including complete blood count and blood chemistry, were within the normal range. She was diagnosed with psoriasis and tinea faciei on her first hospital visit. Although she was treated with oral steroid and anti-histamine medication and topical steroid for three weeks for psoriasis, her skin lesions did not improve. Fungal culture, lactophenol cotton blue staining, skin biopsy, and ribosomal RNA (rRNA) sequencing were done. The fungal culture on potato dextrose agar showed gray, velvety colonies with light yellow background after being subcultured (Fig. 2A). Phialides with chains of oval conidia were observed on lactophenol cotton blue staining (Fig. 2B). Periodic acid-Schiff with diastase (D-PAS) staining revealed pinkish septated fungal elements and mixed inflam- matory and granulomatous infiltrate in the dermis (Fig. 2C). Based on sequence analysis of the internal transcribed spacer region of rRNA gene, P. lilacinum (Table 1) was identified using the GenBank Basic Local Alignment Search Tool (BLAST). The

GenBank BLAST search revealed 100% (963/963 bp) similarity with 126 P. lilacinum strains. Therefore, the final diagnosis was cutaneous P. lilacinum infection. The patient was treated with oral itraconazole (200 mg/day) for four months. Most of the skin lesions were improved after 16 weeks of treatment (Fig. 1B).

Figure 1. (A) Well-demarcated erythematous scaly patch on the forehead (B) The lesion was almost resolved after 16 weeks of treatment.
Figure 2. (A) Gray, velvety colonies with a light yellow back- ground (B) Phialides with chains of oval conidia (lactophenol cotton blue staining, ×400) (C, D) Histopathologic findings show septated fungal elements and mixed inflammatory and granulomatous infiltrates in the dermis (D-PAS, ×200, ×400).

ITS sequence

ATCATTACCGAGTTATACAACTCCCAAACCCACTGTGAACCTTACCTCA-GTTGCCTCGGCGGGAACGCCCCGGCCGCCTGCCCC CGCGCCGGCGCCGGACCCAGGCGCCCGCCGCAGGGACCCCAAACTCTCTTGCA-TTACGCCCAGCGGGCGGAATTTCTTCTCT GAGTTGCACAAGCAAAAACAAATGAATCAAAACTTTCAACAACGGATCTCTTGGTTCTGGCATCGATGAAGAACGCAGCGAAATGCGATAAGTAATGTGAATTGCAGAATTCAGTGAATCATCGAATCTTTGAACGCACATTGCGCCCGCCAGCATTCTGGCGGGCATGCCTGTTCGAGCGTCATTTCAACCCTCGAGCCCCCCCGGGGGCCTCGGTGTTGGGGGACGGCACACCAGCCGCCCCCGAAATGCAGTGGCGACCCCGCCGCAGCCTCCCCTGCGTAGTAGCACACACCTCGCACCGGAGCGCGGAGGCGGTCACGCCGTAAAACGCCCAACTTTCTTAGAGTTGACC.

Table 1. Internal transcribed spacer (ITS) sequence of the rRNA gene used to identify Purpureocillium lilacinum
DISCUSSION

P. lilacinum is a fungal pathogen found in soil and decaying vegetation. Although P. lilacinum infections primarily occur in immunocompromised patients, it is considered an emerging disease in immunocompetent patients as well8. Skin infections caused by P. lilacinum are very rare, and only eight cases have been reported in Korean literature (Table 2)9-16. The present case was a case of cutaneous P. lilacinum infection in an immunocompetent patient who was initially diagnosed with psoriasis and tinea faciei.

The predisposing factors of cutaneous P. lilacinum infec- tions are malignancy, solid and bone marrow transplantation, long-term glucocorticoid use, and other immunosuppressed conditions4; however, several cases occurring in immuno- competent patients have also been reported. Among the 42 reported cases of cutaneous and subcutaneous P. lilacinum infections reported in Korean journals from 1977 to 2004, eight cases (18.6%) had no predisposing factors8. Furthermore, six of the eight (75.0%) patients showed no risk factors for infection, and seven of the eight (87.5%) patients were immunocompetent. Interestingly, the average age of the eight patients was 69.2±22.4 years old, and six of the eight (75.0%) patients were older than 70 years old, which implies that old age possibly has a significant relationship with cutaneous P. lilacinum infections. In this case, the patient was a 72-year-old healthy woman who had no underlying diseases and medication history that would suggest an immunocompetent status.

Cutaneous P. lilacinum infections could manifest clinically as various skin lesions, such as patches, plaques, vesicles, pustules, nodules, and crusts7. This infection primarily involves exposed areas, such as the face, arms, and legs14. Among the eight patients reported in Korean journals, seven cases had lesions in the upper extremities, including the hand, forearm, and shoulder, and one experienced a clear preceding trauma. Only one out of the eight cases had a lesion involving the face. Our patient showed a well-demarcated erythematous scaly patch on the forehead, and this cutaneous finding led to the initial diagnosis of psoriasis and tinea faciei. After the treatment failure for these diagnoses, fungal cultures, histologic studies, and rRNA gene sequencing were conducted, and the diag- nosis of cutaneous P. lilacinum infection was confirmed.

The standard treatment for cutaneous P. lilacinum infections is not yet established, and the treatment is often challenging8. This fungus is highly resistant to conventional antifungal agents, including amphotericin B, fluconazole, and flucytosine, and the results of its in vitro susceptibility tests to itraconazole are conflicting17,18. In contrast, terbinafine or triazole antifungal agents, such as voriconazole, ravuconazole, and posaconazole, broadly showed a low level of minimum inhibitory concen- tration based on their in vitro susceptibility tests14. In the cases reviewed here, including the present case, five patients were successfully treated with itraconazole monotherapy and improved clinically, whereas two patients who showed resistance to this treatment required a combination therapy with voriconazole and terbinafine, respectively11-16. One patient was treated with ketoconazole combined with griseofulvin9, and one patient was treated with skin lesion excision10.

Briefly, we report a case of a localized cutaneous P. lilacinum infection in a healthy patient with no underlying diseases and with clinical manifestations similar to psoriasis. Thus, it is important to suspect this atypical and rare fungal infection when a patient shows a poor treatment response. This study also provides a literature review of cutaneous fungal infections caused by P. lilacinum in Korea.

Author

Age/
Sex

Cutaneous
presentation

Location

Immune status

Predisposing
factor

Treatment

Cho et al.9

19/M

Erythematous patch

Cheek

Immunocompetent

None

Griseofulvin,
Ketoconazole

Shin et al.10

46/M

Erythematous nodules

Forearm

Immunocompromised

Renal
transplantation

Excision

Ko et al.11

83/M

Erythematous plaque

Wrist

Immunocompetent

None

Itraconazole

Hwang et al.12

81/M

Erythematous plaque
and pustules

Hand

Immunocompetent

None

Itraconazole

Jung et al.13

72/M

Erythematous plaque

Shoulder

Immunocompetent

None

Itraconazole,
Voriconazole

Kwak et al.14

81/M

Erythematous
pustular plaque

Dorsal
hand

Immunocompetent

None

Itraconazole

Kim et al.15

85/F

Erythematous plaque

Forearm,
dorsal hand

Immunocompetent

None

Itraconazole, Terbinafine

Jung et al.16

84/M

Erythematous papules
and patch

Forearm

Immunocompetent

Injury from hoe

Itraconazole

Present case

72/F

Erythematous patch

Forehead

Immunocompetent

None

Itraconazole

Table 2. Clinical features of localized cutaneous Purpureocillium lilacinum infection in Korean literature


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