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ID Case Conference
September 4, 2007
Yvonne L. Ballard
Case
CC: right foot pain
 HPI:
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44yo WF with DM presented to vascular
surgery clinic with right foot pain, at
first metatarsal
 Original injury in 04/07, when pt’s toe
got stuck on a fringe in carpet, causing
a fall…pt developed ulcer of right first
toe, which progressively got worse
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PMH:
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Diabetes Mellitus
Hypertension
CHF
Morbid Obesity
SocHx:
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Smokes 1ppd
No Etoh, illicits
No pets
No recent travel
Medications
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Glucophage
Insulin 70/30
Lasix
Lisinopril
Neurontin
Spironolactone
Zocor
Celexa
Aspirin
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NKDA
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FamHx:
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CAD
Sequence of Events
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6/28/07: Pt reports increasing pain to
right first MTP, with associated color
changes of the toe
7/5/07: Seen in Vasc Surg clinic, and
admitted to hospital
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Xray: Osteomyelitis of first great toe, and
grossly displaced calcaneal cuboid joint
Arterial duplex: ABIs of 0.49 and 0.59 in the
anterior and posterior tibial arteries
7/9: Angiography and stenting of R SFA
7/10: Repeat Xray showed multiple displaced
fractures at the mid foot level, and 3rd and 4th
metatarsals
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7/6: bedside debridement (resection of
superficial necrotic skin only in the region
of the first toe)
7/11: Discharged home on IV antibiotics:
Vancomycin, Zosyn
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(stop date of 8/15/07)
7/24: Amputation of first right toe
8/16: re-admitted for new black eschar in
middle of her wound, with increased
drainage
8/16: wound debridement (down to bone)
and biopsy sent to Micro
Physical Exam, 8/21
Vitals: Tm 36.1, BP 107/62, P 56
 Physical Exam:
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Gen: NAD
 CV: RRR
 Resp: CTA B/L
 Ext: large surgical wound on right foot,
wound from amputation shows small
black area at base without purulence
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Labs, 8/21
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WBC 10.3
Hct 36.5
Plt 137
LFTs WNL
Coags WNL
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BUN/Cr: 20/1.5
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ESR 45
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8/21: Discharged home with IV Abx:
Vancomycin
 Ertapenem
 Posaconazole
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Discussion…
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8/16 Biopsy Results:
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4+ Candida parapsilosis
HOWEVER…There was a “significant
amount of mould” growing UNDER
the Candida on the plate
Alternaria alternata
One of the causative agents of
phaeohyphomycosis
 Emerging opportunistic pathogen in
immunosuppressed patients
 Is ubiquitous – common laboratory
contaminant
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Phaeohyphomycosis
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Immunocompetent
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Cutaneous
Subcutaneous
Brain abcesses
Sinusitis
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Other Described
Cases
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Immunocompromised
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Fungemia
Disseminated disease
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Meningitis
Pneumonia
Prosthetic valve
endocarditis
Peritoneal dialysis
catheter infection
Osteomyelitis
Septic Arthritis
Alternaria alternata
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A fungus commonly isolated from plants,
soil, food, and indoor air environment
Produces a melanin-like pigment
A. alternata is the most common species
of >50 species in the Alternaria genus
Colonizes the paranasal sinuses, leading
to chronic hypertrophic sinusitis
Alternaria alternata
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Onychomycosis
Sinusitis
Ulcerated
cutaneous
infections
Keratitis
Visceral infections
Osteomyelitis
Patient Characteristics
See table in:
Lyke KE, Miller NS, Towne L, Merz WG.
A case of cutaneous ulcerative
alternariosis: rare association with
diabetes mellitus and unusual failure of
itraconazole treatment.
Clin Infect Dis. 2001 Apr 15;32(8) 117887. Review
Other species
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A.
A.
A.
A.
A.
A.
chartarum
dianthicola
geophilia
infectoria
stemphyloides
teunissima
Images
To view images of the fungus,
go to Doctor Fungus at:
http://www.doctorfungus.org/index.htm
Macroscopic Features
Grows rapidly on potato glucose
agar (at 25 °C)
 Colony flat, downy/woolly
 Covered by grayish, short aerial
hyphae
 Initially greyish white, later turns
greenish black or olive brown with
light border
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Microscopic Features
Septate brown hyphae
 Simple or branched large conidia,
with transverse and longitudinal
septations
 May produce germ tubes
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Ovoid, darkly pigmented, smooth or
roughened
 End is round, tapers at apex
(beak-like appearance)
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Histopathologic Features
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H&E stain
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Dark colored filamentous hyphae
Fontana-Masson silver stain
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Specific to melanin
Susceptibilities
No standardized in vitro
susceptibility testing
 Caspofungin shown to be active in
vitro
 Voriconazole
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Generated lower MICs than
Itraconazole
Treatment – Case Reports
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Systemic -azoles
Intralesional
Ampho B and
surgical excision
Immunotherapy
Search PubMed
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Alternaria alternata infections
Case reports
 Reviews
 Differential Diagnosis
 Drug Therapy
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