mycoses
Diagnosis,Therapy and Prophylaxis of Fungal Diseases
Case report
Cladosporium cladosporioides: a so far unidentified cause of white piedra €urer S. Zeller, S. Lempert, M. Goebeler, H. Hamm and A. Kolb-Ma Department of Dermatology, Venereology and Allergology, University Hospital Wu€rzburg, Wu€rzburg, Germany
Introduction White piedra (trichomycosis nodosa, trichosporosis nodosa) is a rare superficial fungal infection of the hair shaft appearing as multiple white to tan, adherent nodules. The soft coating is usually removable from the hair shafts. However, the fungus may destroy the hair shaft by invading it at localised points resulting in hair breakage. Pubic and moustache hair as well as scalp hair may be affected. White piedra is typically caused by species of the Trichosporon genus, mainly Trichosporon beigelii. The fungus was isolated in 1902 by J. P. Vuillemin1 and named after the first describer of white piedra, H. Beigel.2,3 Our report is the first observation of a patient with white piedra caused by Cladosporium cladosporioides. The genus Cladosporium is one of the most common dematiaceous fungi that inhabits saprophytic and soil environments. The term dematiaceous refers to fungi whose cell walls produce melanin and, therefore, are naturally pigmented black or brown. Cladosporium is frequently isolated as a contaminant of foods. The fungus forms olivaceous-brown colonies. On light microscopy, simple or branching pigmented conidiophores can be seen with likewise pigmented, ellipsoidal or cylindrical conidia.4 The agent rarely causes human infections, mostly lesions of phaeohyphomycosis. So far, only a single human Cladosporium scalp infection with dark spots at the base of the hair shafts has been described.5
Case report A 55-year-old woman presented with a 6-year history of asymptomatic white deposits on her scalp hair that
Correspondence: Dr Annette Kolb-M€ aurer, Department of Dermatology, €rzburg, JosefVenereology and Allergology, University Hospital Wu €rzburg, Germany Schneider-Str. 2, D – 97080 Wu Tel.: +49 (0) 931 201 26710. Fax: +49 (0) 931 201 26700. E-mail: [email protected] Submitted for publication 22 December 2014 Accepted for publication 11 February 2015
© 2015 Blackwell Verlag GmbH Mycoses, 2015, 58, 315–317
could not be wiped off easily or removed by washing. Furthermore, she recognised brittle hair shafts and mild effluvium. Clinical examination revealed multiple discrete, whitish nodules adherent to the hair shafts of her scalp with accentuation in the crown and vertex area (Fig. 1). Rubbing of affected hairs between two fingers did not remove the nodules completely, but tiny, powdery particles could be scaled off. No scalp erythema or scaling was visible, the hair pull test was negative. Genital hair, eyelashes and eyebrows were unaffected. On dermoscopy, semi-transparent encasements attached to the scalp hair shafts could be seen (Fig. 2). Hair shaft abnormalities, especially trichorrhexis nodosa, were excluded by light microscopy of embedded hair shafts. For microbiological work-up, affected hairs were epilated and skin samples of the scalp were obtained. Direct microscopic examination in non-stained 10% potassium hydroxide revealed spores and hyphae within the nodules (Fig. 3). After 7 days, culture showed velvety, olivaceous-green colonies on Sabouraud agar and malt extract agar (Fig. 4). The reverse of the colonies had a greyish-black colour. Microscopic examination of a lactophenol cotton blue preparation of the colonies revealed growth of Cladosporium species, based upon the key features described by de Hoog et al. [4] with typical septated, irregularly branched conidiophores (Fig. 5). Identification of the subtype Cladosporium cladosporioides was carried out by polymerase chain reaction sequencing of internally transcribed spacer regions (Centraalbureau voor Schimmelcultures, Fungal Biodiversity Centre, Utrecht, The Netherlands). Direct microscopy and culture of skin scales remained negative. Topical treatment with ciclopiroxolamine shampoo was started, for the first 6 weeks daily, and afterwards on every other day. After 12 weeks, marked clinical reduction in the white nodules could be noted but the mycological follow-up control still revealed Cladosporium spp. on Saboraud agar. After 5 months of continuous treatment, the nodular attachments were almost completely vanished and brittle hair was absent. The patient was advised to use ciclopiroxolamine shampoo twice weekly for maintenance therapy.
doi:10.1111/myc.12311
S. Zeller et al.
Figure 1 Clinical presentation with multiple white nodules
Figure 3 Direct light microscopy of a nodule in 10% potassium
alongside scalp hair shafts.
hydroxide displaying spores and hyphae coated by a cement-like substance (magnification, 9200).
Figure 2 Dermoscopy showing semi-transparent, oblong deposits
along the hair shafts (magnification, 910).
Figure 4 Affected hair shafts in culture presenting with oliva-
ceous-green, velvety colonies on Sabouraud’s dextrose agar.
Discussion Cladosporium cladosporioides causes a variety of clinical infections in immunocompromised and immunocompetent humans.6 Its airborne spores are relevant allergens, which may harm asthmatic patients. Moreover, lung infections such as a pulmonary fungus ball, dental granulomas, brain abscesses and eye infections presenting as keratomycosis and corneal ulcer have been described.7 Furthermore, there are different kinds of skin infections that can be caused by inoculation of the mould. In particular, cutaneous and subcutaneous phaeohyphomycosis are regularly reported in humans and animals varying from a superficial dermatitis with erythema, swelling and pruritus, to large indurated, subcutaneous lesions with suppuration and pus-draining sinuses.7–11 Ecthyma- or cyst-like variants of phaeohyphomycoses may occur as well.6,12
316
Scalp infections with Cladosporium cladosporioides seem to be very rare. There is only a single case report by Sosa et al. [5] on a girl with a 3-year history of mild hair loss and pruritus of her scalp. Similar to our patient, the girl suffered from diffusely thin, brittle hair from the frontal to occipital area without evidence of erythema or scaling of the skin. Only black dots scattered among the bases of the hair shafts rather than white nodules as they are typically found in white piedra were described in this girl. It is remarkable that in our case a dematiaceous, brown to black pigmented fungus, that is Cladosporium cladosporioides, caused the same clinical features as the yeast Trichosporon beigelii, the prevailing pathogen in white piedra. Both fungi are saprophytic soil inhabitants, widely spread in the environment and commonly found in soil, rotten wood and on living and dead plant material. Cladosporium cladosporioides can also be
© 2015 Blackwell Verlag GmbH Mycoses, 2015, 58, 315–317
White piedra caused by C. cladosporioides
nonhazardous topical therapy with the wide-spectrum antimycotic ciclopiroxolamine in form of a shampoo. The lesions resolved slowly, but continuously. In conclusion, white piedra presents a clinical pattern of fungal hair infection that can not only be caused by Trichosporon beigelii but also by Cladosporium cladosporioides. It needs to be awaited whether even more currently unknown pathogens may have the ability to provoke such an infection pattern. Independent of its aetiology, treatment of white piedra needs patience.
Conflict of interest Figure 5 Light microscopy of lactophenol cotton blue prepara-
tion of colonies grown on Sabouraud’s dextrose agar presenting with simple or branching, pigmented conidiophores with pigmented, ellipsoidal or cylindrical conidia (magnification, 91000).
traced on decayed foods as well as on animal faeces and is furthermore used as an entomopathogenic fungus for the biological control of different species of insects.11,12 As in our case, the white nodules commonly consist of conidiophores and conidia, coated by a cement-like substance. In a patient with trichosporosis caused by Trichosporon beigelii, de Almeida et al. [13] saw elimination of spores from the nodule surface using scanning electron microscopy. It may be assumed that the powdery accretions on the hair of our patient represented the clinical correlate for infectious spores, even though the mode of transmission of white piedra in man is not clear yet. There are quite a number of whitish attachments to scalp hairs which can be mistaken for white piedra. Differential diagnosis includes nits of head lice, ‘book lice’ (Liposcelis bostrychophilus), coarse flakes, idiopathic or parakeratotic hair casts, sand, fluff, hair spray remnants and trichorrhexis nodosa. For clinical differentiation, inspection by magnifying glass, dermoscopy and assessment of removability and movability of the particle along the hair shaft is helpful. Treatment of white piedra is often a therapeutic challenge.14 Shaving or cutting off affected hair is the easiest method but rarely accepted.15 Oral itraconazole has been shown to be very effective in the treatment of phaeohyphomycosis caused by Cladosporium cladosporioides5,7,11 as well as for infections with Trichosporon beigelii.14 In our case, with regard to an isolated hair shaft infection, we decided to start a
© 2015 Blackwell Verlag GmbH Mycoses, 2015, 58, 315–317
None.
References 1
2
3 4
5 6
7
8
9
10 11
12
13 14 15
M€ uller G, Meyer H. The cause of piedra, Trichosporon beigelii (K€ uchenmeister et Rabenhorst, 1867) Vuillemin, 1902. Zentralbl Bakteriol 1968; 206: 542–9. Youker S, Andreozzi R, Appelbaum P, Credito K, Miller J. White piedra: further evidence of a synergistic infection. J Am Acad Dermatol 2003; 49: 746–9. Beigel H. O genero Trichosporon. Rev Med Cir do Bras 1930; 38: 251–61. De HG, Guarro J, Gene J, Figueras M. Atlas of Clinical Fungi, 3rd edn. Utrecht, The Netherlands; Reus, Spain: Centrallbureau voor Schimmelcultures Universitat Rovira i Virgili, 2009. Sosa E, Cohen P, Tschen J. Cladosporium scalp infection. Skinmed 2012; 10: 393–4. Tamsikar J, Naidu J, Singh S. Phaeohyphomycotic sebaceous cyst due to Cladosporium cladosporioides: case report and review of literature. J Mycol Med 2006; 16: 55–57. Ma X, Gu Y, Liu X et al. Phaeohyphomycotic dermatitis in a giant panda (Ailuropoda melanoleuca) caused by Cladosporium cladosporioides. Med Mycol Case Rep 2013; 2: 119–21. Annessi G, Cimitan A, Zambruno G, Di Silverio A. Cutaneous phaeohyphomycosis due to Cladosporium cladosporioides. Mycoses 1992; 35: 243–6. Gugnani H, Sood N, Singh B, Makkar R. Case report. Subcutaneous phaeohyphomycosis due to Cladosporium cladosporioides. Mycoses 2000; 43: 85–87. Vieira M, Milheiro A, Pacheco F. Phaeohyphomycosis due to Cladosporium cladosporioides. Med Mycol 2001; 39: 135–7. Sang H, Zheng XE, Zhou WQ et al. A case of subcutaneous phaeohyphomycosis caused by Cladosporium cladosporioides and its treatment. Mycoses 2012; 55: 195–7. Duquia R, de Almeida HJ, Vettorato G, Rocha N, de Castro L. Ecthyma-like phaeohyphomycosis caused by Cladosporium cladosporioides. Mycoses 2010; 53: 541–3. De Almeida HJ, Rivitti E, Jaeger R. White piedra: ultrastructure and a new microecological aspect. Mycoses 1990; 33: 491–7. Khandpur S, Reddy B. Itraconazole therapy for white piedra affecting scalp hair. J Am Acad Dermatol 2002; 47: 415–18. Tambe S, Dhurat S, Kumar C et al. Two cases of scalp white piedra caused by Trichosporon ovoides. Indian J Dermatol Venereol Leprol 2009; 75: 293–5.
317
Copyright of Mycoses is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Diagnosis,Therapy and Prophylaxis of Fungal Diseases
Case report
Cladosporium cladosporioides: a so far unidentified cause of white piedra €urer S. Zeller, S. Lempert, M. Goebeler, H. Hamm and A. Kolb-Ma Department of Dermatology, Venereology and Allergology, University Hospital Wu€rzburg, Wu€rzburg, Germany
Introduction White piedra (trichomycosis nodosa, trichosporosis nodosa) is a rare superficial fungal infection of the hair shaft appearing as multiple white to tan, adherent nodules. The soft coating is usually removable from the hair shafts. However, the fungus may destroy the hair shaft by invading it at localised points resulting in hair breakage. Pubic and moustache hair as well as scalp hair may be affected. White piedra is typically caused by species of the Trichosporon genus, mainly Trichosporon beigelii. The fungus was isolated in 1902 by J. P. Vuillemin1 and named after the first describer of white piedra, H. Beigel.2,3 Our report is the first observation of a patient with white piedra caused by Cladosporium cladosporioides. The genus Cladosporium is one of the most common dematiaceous fungi that inhabits saprophytic and soil environments. The term dematiaceous refers to fungi whose cell walls produce melanin and, therefore, are naturally pigmented black or brown. Cladosporium is frequently isolated as a contaminant of foods. The fungus forms olivaceous-brown colonies. On light microscopy, simple or branching pigmented conidiophores can be seen with likewise pigmented, ellipsoidal or cylindrical conidia.4 The agent rarely causes human infections, mostly lesions of phaeohyphomycosis. So far, only a single human Cladosporium scalp infection with dark spots at the base of the hair shafts has been described.5
Case report A 55-year-old woman presented with a 6-year history of asymptomatic white deposits on her scalp hair that
Correspondence: Dr Annette Kolb-M€ aurer, Department of Dermatology, €rzburg, JosefVenereology and Allergology, University Hospital Wu €rzburg, Germany Schneider-Str. 2, D – 97080 Wu Tel.: +49 (0) 931 201 26710. Fax: +49 (0) 931 201 26700. E-mail: [email protected] Submitted for publication 22 December 2014 Accepted for publication 11 February 2015
© 2015 Blackwell Verlag GmbH Mycoses, 2015, 58, 315–317
could not be wiped off easily or removed by washing. Furthermore, she recognised brittle hair shafts and mild effluvium. Clinical examination revealed multiple discrete, whitish nodules adherent to the hair shafts of her scalp with accentuation in the crown and vertex area (Fig. 1). Rubbing of affected hairs between two fingers did not remove the nodules completely, but tiny, powdery particles could be scaled off. No scalp erythema or scaling was visible, the hair pull test was negative. Genital hair, eyelashes and eyebrows were unaffected. On dermoscopy, semi-transparent encasements attached to the scalp hair shafts could be seen (Fig. 2). Hair shaft abnormalities, especially trichorrhexis nodosa, were excluded by light microscopy of embedded hair shafts. For microbiological work-up, affected hairs were epilated and skin samples of the scalp were obtained. Direct microscopic examination in non-stained 10% potassium hydroxide revealed spores and hyphae within the nodules (Fig. 3). After 7 days, culture showed velvety, olivaceous-green colonies on Sabouraud agar and malt extract agar (Fig. 4). The reverse of the colonies had a greyish-black colour. Microscopic examination of a lactophenol cotton blue preparation of the colonies revealed growth of Cladosporium species, based upon the key features described by de Hoog et al. [4] with typical septated, irregularly branched conidiophores (Fig. 5). Identification of the subtype Cladosporium cladosporioides was carried out by polymerase chain reaction sequencing of internally transcribed spacer regions (Centraalbureau voor Schimmelcultures, Fungal Biodiversity Centre, Utrecht, The Netherlands). Direct microscopy and culture of skin scales remained negative. Topical treatment with ciclopiroxolamine shampoo was started, for the first 6 weeks daily, and afterwards on every other day. After 12 weeks, marked clinical reduction in the white nodules could be noted but the mycological follow-up control still revealed Cladosporium spp. on Saboraud agar. After 5 months of continuous treatment, the nodular attachments were almost completely vanished and brittle hair was absent. The patient was advised to use ciclopiroxolamine shampoo twice weekly for maintenance therapy.
doi:10.1111/myc.12311
S. Zeller et al.
Figure 1 Clinical presentation with multiple white nodules
Figure 3 Direct light microscopy of a nodule in 10% potassium
alongside scalp hair shafts.
hydroxide displaying spores and hyphae coated by a cement-like substance (magnification, 9200).
Figure 2 Dermoscopy showing semi-transparent, oblong deposits
along the hair shafts (magnification, 910).
Figure 4 Affected hair shafts in culture presenting with oliva-
ceous-green, velvety colonies on Sabouraud’s dextrose agar.
Discussion Cladosporium cladosporioides causes a variety of clinical infections in immunocompromised and immunocompetent humans.6 Its airborne spores are relevant allergens, which may harm asthmatic patients. Moreover, lung infections such as a pulmonary fungus ball, dental granulomas, brain abscesses and eye infections presenting as keratomycosis and corneal ulcer have been described.7 Furthermore, there are different kinds of skin infections that can be caused by inoculation of the mould. In particular, cutaneous and subcutaneous phaeohyphomycosis are regularly reported in humans and animals varying from a superficial dermatitis with erythema, swelling and pruritus, to large indurated, subcutaneous lesions with suppuration and pus-draining sinuses.7–11 Ecthyma- or cyst-like variants of phaeohyphomycoses may occur as well.6,12
316
Scalp infections with Cladosporium cladosporioides seem to be very rare. There is only a single case report by Sosa et al. [5] on a girl with a 3-year history of mild hair loss and pruritus of her scalp. Similar to our patient, the girl suffered from diffusely thin, brittle hair from the frontal to occipital area without evidence of erythema or scaling of the skin. Only black dots scattered among the bases of the hair shafts rather than white nodules as they are typically found in white piedra were described in this girl. It is remarkable that in our case a dematiaceous, brown to black pigmented fungus, that is Cladosporium cladosporioides, caused the same clinical features as the yeast Trichosporon beigelii, the prevailing pathogen in white piedra. Both fungi are saprophytic soil inhabitants, widely spread in the environment and commonly found in soil, rotten wood and on living and dead plant material. Cladosporium cladosporioides can also be
© 2015 Blackwell Verlag GmbH Mycoses, 2015, 58, 315–317
White piedra caused by C. cladosporioides
nonhazardous topical therapy with the wide-spectrum antimycotic ciclopiroxolamine in form of a shampoo. The lesions resolved slowly, but continuously. In conclusion, white piedra presents a clinical pattern of fungal hair infection that can not only be caused by Trichosporon beigelii but also by Cladosporium cladosporioides. It needs to be awaited whether even more currently unknown pathogens may have the ability to provoke such an infection pattern. Independent of its aetiology, treatment of white piedra needs patience.
Conflict of interest Figure 5 Light microscopy of lactophenol cotton blue prepara-
tion of colonies grown on Sabouraud’s dextrose agar presenting with simple or branching, pigmented conidiophores with pigmented, ellipsoidal or cylindrical conidia (magnification, 91000).
traced on decayed foods as well as on animal faeces and is furthermore used as an entomopathogenic fungus for the biological control of different species of insects.11,12 As in our case, the white nodules commonly consist of conidiophores and conidia, coated by a cement-like substance. In a patient with trichosporosis caused by Trichosporon beigelii, de Almeida et al. [13] saw elimination of spores from the nodule surface using scanning electron microscopy. It may be assumed that the powdery accretions on the hair of our patient represented the clinical correlate for infectious spores, even though the mode of transmission of white piedra in man is not clear yet. There are quite a number of whitish attachments to scalp hairs which can be mistaken for white piedra. Differential diagnosis includes nits of head lice, ‘book lice’ (Liposcelis bostrychophilus), coarse flakes, idiopathic or parakeratotic hair casts, sand, fluff, hair spray remnants and trichorrhexis nodosa. For clinical differentiation, inspection by magnifying glass, dermoscopy and assessment of removability and movability of the particle along the hair shaft is helpful. Treatment of white piedra is often a therapeutic challenge.14 Shaving or cutting off affected hair is the easiest method but rarely accepted.15 Oral itraconazole has been shown to be very effective in the treatment of phaeohyphomycosis caused by Cladosporium cladosporioides5,7,11 as well as for infections with Trichosporon beigelii.14 In our case, with regard to an isolated hair shaft infection, we decided to start a
© 2015 Blackwell Verlag GmbH Mycoses, 2015, 58, 315–317
None.
References 1
2
3 4
5 6
7
8
9
10 11
12
13 14 15
M€ uller G, Meyer H. The cause of piedra, Trichosporon beigelii (K€ uchenmeister et Rabenhorst, 1867) Vuillemin, 1902. Zentralbl Bakteriol 1968; 206: 542–9. Youker S, Andreozzi R, Appelbaum P, Credito K, Miller J. White piedra: further evidence of a synergistic infection. J Am Acad Dermatol 2003; 49: 746–9. Beigel H. O genero Trichosporon. Rev Med Cir do Bras 1930; 38: 251–61. De HG, Guarro J, Gene J, Figueras M. Atlas of Clinical Fungi, 3rd edn. Utrecht, The Netherlands; Reus, Spain: Centrallbureau voor Schimmelcultures Universitat Rovira i Virgili, 2009. Sosa E, Cohen P, Tschen J. Cladosporium scalp infection. Skinmed 2012; 10: 393–4. Tamsikar J, Naidu J, Singh S. Phaeohyphomycotic sebaceous cyst due to Cladosporium cladosporioides: case report and review of literature. J Mycol Med 2006; 16: 55–57. Ma X, Gu Y, Liu X et al. Phaeohyphomycotic dermatitis in a giant panda (Ailuropoda melanoleuca) caused by Cladosporium cladosporioides. Med Mycol Case Rep 2013; 2: 119–21. Annessi G, Cimitan A, Zambruno G, Di Silverio A. Cutaneous phaeohyphomycosis due to Cladosporium cladosporioides. Mycoses 1992; 35: 243–6. Gugnani H, Sood N, Singh B, Makkar R. Case report. Subcutaneous phaeohyphomycosis due to Cladosporium cladosporioides. Mycoses 2000; 43: 85–87. Vieira M, Milheiro A, Pacheco F. Phaeohyphomycosis due to Cladosporium cladosporioides. Med Mycol 2001; 39: 135–7. Sang H, Zheng XE, Zhou WQ et al. A case of subcutaneous phaeohyphomycosis caused by Cladosporium cladosporioides and its treatment. Mycoses 2012; 55: 195–7. Duquia R, de Almeida HJ, Vettorato G, Rocha N, de Castro L. Ecthyma-like phaeohyphomycosis caused by Cladosporium cladosporioides. Mycoses 2010; 53: 541–3. De Almeida HJ, Rivitti E, Jaeger R. White piedra: ultrastructure and a new microecological aspect. Mycoses 1990; 33: 491–7. Khandpur S, Reddy B. Itraconazole therapy for white piedra affecting scalp hair. J Am Acad Dermatol 2002; 47: 415–18. Tambe S, Dhurat S, Kumar C et al. Two cases of scalp white piedra caused by Trichosporon ovoides. Indian J Dermatol Venereol Leprol 2009; 75: 293–5.
317
Copyright of Mycoses is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
