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ID Case Conference September 4, 2007 Yvonne L. Ballard Case CC: right foot pain HPI: 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 PMH: Diabetes Mellitus Hypertension CHF Morbid Obesity SocHx: Smokes 1ppd No Etoh, illicits No pets No recent travel Medications Glucophage Insulin 70/30 Lasix Lisinopril Neurontin Spironolactone Zocor Celexa Aspirin NKDA FamHx: CAD Sequence of Events 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 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 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 (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: 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 Labs, 8/21 WBC 10.3 Hct 36.5 Plt 137 LFTs WNL Coags WNL BUN/Cr: 20/1.5 ESR 45 8/21: Discharged home with IV Abx: Vancomycin Ertapenem Posaconazole Discussion… 8/16 Biopsy Results: 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 Phaeohyphomycosis Immunocompetent Cutaneous Subcutaneous Brain abcesses Sinusitis Other Described Cases Immunocompromised Fungemia Disseminated disease Meningitis Pneumonia Prosthetic valve endocarditis Peritoneal dialysis catheter infection Osteomyelitis Septic Arthritis Alternaria alternata 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 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 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 Microscopic Features Septate brown hyphae Simple or branched large conidia, with transverse and longitudinal septations May produce germ tubes Ovoid, darkly pigmented, smooth or roughened End is round, tapers at apex (beak-like appearance) Histopathologic Features H&E stain Dark colored filamentous hyphae Fontana-Masson silver stain Specific to melanin Susceptibilities No standardized in vitro susceptibility testing Caspofungin shown to be active in vitro Voriconazole Generated lower MICs than Itraconazole Treatment – Case Reports Systemic -azoles Intralesional Ampho B and surgical excision Immunotherapy Search PubMed Alternaria alternata infections Case reports Reviews Differential Diagnosis Drug Therapy