Covid Alert


Print ISSN:-2581-5725

Online ISSN:-2456-9267

CODEN : IACHCL

Current Issue

Year 2020

Volume: 5 , Issue: 2

  • Article highlights
  • Article tables
  • Article images

Article Access statistics

Viewed: 77

Emailed: 0

PDF Downloaded: 80

Barathi, Thanka, and Shalini: Diagnostic challenges of a spectrum of cases of Phaeohyphomycosis - A histopathological approach of rare dematiaceous (Melanized / pigmented) fungi


Introduction

Dematiaceous fungi are a heterogeneous group of melanized fungi found ubiquitously in the environment. There are more than 60 genus and 100 species found worldwide.1 Majority of the filamentous forms (moulds), and few yeast forms are pathogenic to humans. One common pathogenic factor is the presence of melanin pigment on their cell wall, which imparts light to dark golden brown colour to these fungi on HPE which is a characteristic distinguishing feature from other groups.2 Hence the term melanized fungi are now preferred to dematiaceous fungi.3 The three common melanized fungi are phaeohyphomycosis, chromoblastomycosis and mycetoma.4 Unlike the other fungal infections, these dematiaceous fungi have an indolent course and asymptomatic in their presentation. Clinically fungal infection was not thought as primary diagnosis in all these cases and hence in this article we tried to evaluate a simple algorithm of diagnostic approach which would be beneficial to all practicing pathologists if they come across such rare cases.

Materials and Methods

We could retrieve 34 cases of these rare fungi diagnosed in our department from 2011 to 2018. As a routine protocol for any suppurative lesion on H&E sections, we performed special stains for fungus like Periodic Acid Schiff (PAS), PAS-Diastase (PAS-D), Grocott’s Methanamine Silver (GMS) and Acid fast Bacilli (AFB) for mycobacterium to demonstrate the microorganisms. Though we could diagnose pigmented fungi on H&E in many cases, we did the above mentioned fungal stains for all the cases as per our standard operating procedure (SOP). Clinical data was obtained from the medical records department and lab investigation reports obtained from the local area network system in place.

Results

In this study there were 34 cases of dematiaceous fungi diagnosed on HPE. 29/34 is phaeohyphomycosis and 5 were mycetoma and we did not come across chromoblastomycosis in our study. Out of 34 patients there were 24 males and 10 females, age ranging between 13 and 75, predominantly seen in patients above 50 years of age. Ten of them were known diabetic. Six of them were post renal transplant patients. The various clinico-pathological presentations of the patients revealed the indolent course of the disease process, except for one case with cerebellar abscess and another case with suspected parietal SOL who presented to the emergency with vomiting, severe headache and difficulty in walking. All other patients presented to the surgical outpatient department for a chronic painless swelling or chronic sinusitis. Even in post transplant cases three had fungal sinusitis and the other 3 had cutaneous / subcutaneous lesions of the extremities requiring surgical excision only. Summary of clinico-pathological data of all 34 cases is given in Table 1.

In patient with cerebellar abscess since they drained more pus, material was sent for AFB and fungal culture along with the HPE. Turnaround time for reporting for routine small biopsy specimen in our department is 2 days, so a critical alert was made when we saw these melanized fungi on H&E. Timely diagnosis helped the clinician to start an appropriate anti fungal regimen which saved the life of that patient. Mycology culture report after 2 weeks confirmed the growth of cladophialophora species.

In our study we found subcutaneous and cutaneous as predominant presentation [23 cases], followed by 9 cases of sinusitis and 2 systemic cases in the form of cerebellar and cerebral abscess.5, 6, 7 Except for couple of cases, fungal infection was not suspected clinically as was evident from the clinical diagnosis mentioned in the HPE request form. 8 Fourteen patients were immunocompromised and 20 were immunocompetent.

One common histopathological feature under microscopy that we observed in all cases of phaeohyphomycosis was a dense necroinflammatory tissue reaction comprising of aggregates of histiocytes lining the cyst wall in a palisading pattern along with numerous giant cells. Variably pigmented melanized fungi were seen lying freely and also within the giant cells lining the tissue. The characteristic morphological features of these fungi were, short hyphal forms [2-6µm] of varying length with infrequent branching and narrow band of constriction at the site of septations giving a beaded appearance.9, 10 Some of them showed bulbous spores [globose or vesicular] at the end of the hyphae which is termed as terminal or intercalated vesicles by many authors. In all cases special stains confirmed the presence of fungi. [Figure 1]

In 5 cases of mycetoma, subcutaneous tissue showed multiple microabscessess with brown colour pigmented fungal colonies with Splendore Hoeppli phenomenon [deposition of amorphous, eosinophilic hyaline material around the fungal colonies]. The filamentous fungal hyphae showed vesicular bulbous ends [chlamydoconidia]. 11 Focal giant cell reaction with reactive fibrosis and chronic inflammatory response surrounding the micro abscess was also seen. 12 In addition to the clinico-pathological data given in table 1 we also analyzed total count and differential count of all the patients. Clinical pathology reports were available for only 19 cases and 12 of that showed leukocytosis and Neutrophilia.

Table 1

Summary ofClinico-pathological data from 34 cases of dematiaceous fungi.

S.No Age/ Sex Clinical    Risk Factors Presentation Anatomical site of Lesion Clinical Diagnosis
1. 60/M Difficulty in walking DM Left Cerebellum Abscess
2. 54/M Nasal Block RT/DM Maxillary Sinus Sinusitis
3. 65/M Bursitis DM Right ankle Dermoid cyst
4. 65/M Ulcer DM Left leg Venous ulcer
5. 55/F Swelling NIL Left Lower Limb Lipoma
6. 50/F Swelling DM Leg Dermoid cyst
7. 51/F Nasal bleed RT Maxillary sinus Papilloma
8. 50/F Nasal mass RT Left Maxillary sinus Sinusitis
9. 52/M Skin wart RT Finger Verruca vulgaris
10. 55/M Swelling RT Dorsum of foot Histoplasmosis
11. 35/M Chronic Ulcer RT Left foot Non healing ulcer
12. 45/F Skin lesion NIL Skin nodule Topical eczema
13. 54/M Nasal mass NIL Left nasal mass Allergic polyp
14. 40/M Swelling NIL Right foot Ganglion cyst
15. 45/F Lump NIL Right Toe Bunion
16. 59/M Swelling NIL Left wrist Ganglion
17. 31/M Sinusitis NIL Right maxilla Osteomyelitis
18. 24/M Sinonasal mass NIL Left maxilla ?Growth
19. 24/M Nasal mass NIL Left maxilla ?Growth
20. 62/M Pressure sore NIL Left Trochanter Pseudo tumor
21. 58/F Swelling NIL Left thigh Abscess
22. 68/F Swelling DM Left foot Abscess
23. 53/F Ulcer NIL Right foot Venous ulcer
24. 75/M Bursitis NIL Left Bursa Bursitis
25. 52/M Nasal mass DM Left maxilla Sinusitis
26. 26/M Swelling NIL Right Hip region Sarcoma
27. 13/M Vomiting NIL Right Parietal SOL
28. 62/M Swelling DM Right Ankle Bursitis
29. 60/M Swelling DM Left Leg and Hand Sebaceous cyst
30. 41/F Ulcer NIL Foot Dermoid
31. 64/M Swelling NIL Right foot Non healing ulcer
32. 60/M Swelling NIL Left Great Toe Gout
33. 33/M Swelling DM Right foot ? Madura foot
34. 60/M Swelling DM Foot Cellulites

[i] S.NO 1 to 29 cases were diagnosed as Phaeohyphomycosis and 30 to 34 were diagnosed as Mycetoma on HPE. DM – Diabetes Mellitus, RT – Renal Transplant.

Table 2

Histological differences between the three keydematiaceous fungi.

Histological Feature Phaeohyphomycosis Eumycotic mycetoma Chromoblastomycosis
Macroscopy No granules Black granules or grains [sulphur granules] No granules
Microscopy
• Pattern Stellate abscess with palisading epithelioid histiocytes and giant cells. Multiple abscesses extensive fibrosis, and formation of sinus tracts. Mixed suppurative and granulomatous lesion
• Cells Moniliform cells Multicellular grains Muriform cells
• Hyphae Short closely septate hyphae [2-6µm] and budding yeasts Broad septate fungal hyphae [2-6µm] or more Round, thick walled, nonseptate hyphae [Sclerotic bodies] [5-12 µm]
• Others Characteristic constriction at the site of septation giving a beaded appearance to the fungi Splendore Hoeppli material borders the granules Pseudoepitheliomatous hyperplasia of the overlying epidermis may be seen
• Melanin Present [Light to dark golden brown] Present [brown] Present [Dark brown]

Figure 1

a: - Brown coloured fungal spores and hyphae ofphaeohyphomycosis within the giant cells H&E 400, b: - PAS stain showing bulbous spores X 400, c: - Silver stain highlighting the characteristic beaded appearance of hyphae X 400, d: - Fungal colonies of mycetoma H&E X40.

https://s3-us-west-2.amazonaws.com/typeset-media-server/932010a4-91a1-4a25-bd0d-78b516a7641cimage1.png
Figure 2

Algorithm ofhistopathological approach to melanized fungi.

https://s3-us-west-2.amazonaws.com/typeset-media-server/932010a4-91a1-4a25-bd0d-78b516a7641cimage2.png

Discussion

Dematiaceous fungi otherwise called as ‘phaeoid molds’ are a heterogeneous group of melanized fungi, which are ubiquitous in nature and found worldwide in dust, soil, wood splinters and decaying vegetations. 13 Phaeohyphomycosis, chromoblastomycosis, and eumycotic mycetoma are some of the relatively common pathogenic melanized fungi. The term phaeohyphomycosis was proposed by Ajello et al in 1974.14 The disease caused by this group of fungi is uncommon in clinical setting, but because of their ubiquitous nature and constant exposure to these fungi in the environment, there is an increased risk of acquiring this disease in both immunocompetent host and immunosuppressed patients.15, 16 Because of increasing immunosuppression either due to lifestyle diseases like diabetes or any other chronic infections and increased medical therapy, there are new species detected on culture by many referral mycology labs.17

Moreover depending on host susceptibility the clinical presentation may be varied and a common mode of infection in most of the cases would be a trivial penetrating injury or a minor trauma which may not be remembered by the patient. As the lesion is localized and chronic in nature, recalling the event by the patient is difficult to elicit in the history. 18 Because of their chronicity and insidious enlargement of swelling there is no clinical suspicion of these fungi, and most of the cases undergo surgical excision which itself is curative.19 Since the excised specimen is sent in formalin for HPE, there would be no residual material for culture examination most of the time. Both clinically and radiologically undiagnosed cases are primarily diagnosed on HPE. In our study 32 out of 34 cases presented like a chronic swelling or sinusitis with a need of surgical excision as the first line of treatment. Hence it is the HPE which clinched the diagnosis and there was no material available for microbiology culture.

Melanized fungi are heterogeneous group of organism having in common melanin pigment on their wall. Since all of them have melanin on their wall the histomorphological differences between each other is important in distinguishing them on H & E sections. In our study we mainly had phaeohyphomycosis and few cases of mycetoma and did not come across chromoblastomycosis. We observed that most of our cases had lesion that is localized to the subcutaneous tissue commonly involving the exposed parts like feet, toes, fingers etc..., which are prone for injurious agents like splinters and thorns. A trivial injury triggers a granulomatous response in the host which is superadded with an acute suppurative reaction to the fungal antigen. Histological differences between the three dematiaceous fungi are given in the Table 2.

Melanin is the antigenic factor expressed by these fungi as a protective mechanism against the host immune system. Melanin is thought to offer protection from environmental stress such as radiation, extremes of temperature and hydrolytic enzymes thus enhancing the virulence and pathogenicity of some fungi. Presence of melanin may be the reason for their ubiquitous nature helping them to survive in the extraneous environment.20

Fungal melanin is dihydroxy-naphthalene [DHN] melanin which is located in the fungal cell wall synthesized via the pentaketide pathway. The difference between fungal melanin and the mammalian melanin is the presence of nitrogen in the later due to the DOPA [Dihydroxy phenylalanine] precursor. Dematiaceous fungi differ from some melanin containing fungal genera [e.g. Cryptococcus] in that they have DHN melanin whereas the later has mammalian type of melanin on their wall. Melanin binds to the hydrolytic enzymes preventing their action on fungal plasma membrane and also acts as a scavenger of free radicals, thus protecting fungi against U-V radiation. Hence melanized fungi are less susceptible than non-melanized fungi to killing by hypochlorite and oxygen and nitrogen derived radicals, thus melanin acting as a virulence factor.21

Another important concern about the presence of melanin in the fungal cell wall is that melanin reduces the effectiveness of certain antifungal agents by directly binding to them or by reducing the porosity by the closely spaced melanin granules, which prevents the larger molecules of drug particles from reaching their target sites. Though this group of fungi are subtle in their clinical presentation, this property of the fungal melanin against the antifungal agents especially in immunocompromised host may be lethal. Hence an HPE diagnosis of melanized fungi would help the clinician in choosing appropriate antifungal like azoles, that doesn’t bind to the melanin so that these fungi are susceptible to this group of drugs.22

We know in general immunocompromised patients are more susceptible to opportunistic fungal infections. But there are certain host factors that allow immunocompetent persons to become victim of fungal infections. Some of the host factors responsible are extremes of age, burns, chronic respiratory diseases where there is a breech in the mucosal/cutaneous barrier mechanism, dialysis, diabetes [Neutropenia] and traumatic injury, suppression of humoral or cellular immune mechanism by any agents/drugs, Genetic polymorphism causing changes in innate immunity etc.23 Leucopenia or neutrophil / monocyte phagocytic dysfunction may also contribute to the disturbance in host defence mechanism. Antibiotics may reduce even normal bacterial flora of the body that normally inhibit fungal overgrowth. Whenever there is an imbalance in this immune mechanism the fungal antigens easily gain entry into the host tissue and elicit granulomatous / suppurative reaction depending on the site of involvement. According to Folder and McGinnis there are four groups of phaeohyphomycosis - Cutaneous / corneal [Keratitis], Subcutaneous, Sinusitis, and Systemic forms based on their location. In our study we came across all the four groups of these fungi.24, 25

Why we emphasise on HPE as an important tool in diagnosis of this group of melanized fungi is, most of the lesions are misdiagnosed as chronic swelling and hence surgical excision is done completely without any residual material for microbiological culture. 26 Biochemical tests like nitrate and carbohydrate assimilation tests are nowadays done in some labs for certain group of fungi. Even molecular techniques using Polymerase Chain Reaction [PCR] and DNA hybridization are also available in some laboratories for specific genera, but not as a routine for dematiaceous fungi. But there is no simple diagnostic tests like routine serological examination or PCR methods available to identify infections due to these fungi in clinical laboratory partly due to their diversity and due to cross reactions with other fugal antigens like aspergillous galactomannan.

Fungal culture should be done for species identification whenever possible. We know that culture is more specific for species isolation, but HPE provides indisputable evidence of tissue invasion and therefore can confirm the pathogenic significance of a cultural isolate that belongs to the normal body flora or that is usually encountered as an environmental contaminant in culture. But HPE shows tissue invasion as hallmark of pathogenic fungi. HPE also confirms the coexistence of other fungi or protozoa/viruses [cytopathic effect or inclusions], so that appropriate therapy and management can be decided by the clinician especially in immunocompromised patients. The advantage of HPE over culture is the time taken for identification. Though we rely on culture only for species categorization a KOH mount would help in genus identification. Because management of one mycosis may be entirely different from that of another, clinician cannot wait for 2-6 weeks time for growth of fungi on culture media to confirm. With the help of HPE the pathologist must often play a key role in recognizing these melanized fungi and alert the clinician for commencement of appropriate antifungal treatment.27

Unless there is a strong suspicion of fungal infection during surgery the material is usually not sent to microbiology laboratory for KOH mount or mycology culture. If sent for culture the material is kept for up to 10 weeks before being discarded as negative. HPE shows 85% sensitivity on H&E sections and with GMS [silver stains] 100% sensitivity.28, 29 The role of HPE in this rare group of fungi is highlighted in this article and hence to make an awareness amongst the pathologist to carefully look into these subtle features on H&E in any microscopic suppurative lesion.

Conclusion

We discussed in this article in detail the varied clinical presentation, important host factors, histomorphological appearance and a diagnostic approach to this rare group of melanized fungi. Since these fungal infections are subclinical in presentation and was not suspected by clinician in most of the cases, and because of their subtle nature on histological examination, a careful search for these organisms by pathologist on HPE would help the treating physician in achieving appropriate treatment and prevent recurrence.

Source of Funding

None.

Conflict of Interest

None.

References

1 

J A Elias R M Michael A P Michael Clinical mycologyChurchill Livingstone ElsevierNew York2009

2 

E Reiss H J Shadomy G M Lyon Fundamental Medical MycologyWiley-Blackwell2012

3 

Sanjay G. Revankar Dematiaceous fungiMycoses200750291101

4 

Sanjay G. Revankar Deanna A. Sutton Melanized Fungi in Human DiseaseClin Microbiol Rev 201023488428

5 

V P Baradkar M Mathur S Kumar Phaeohyphomycosis of subcutaneous tissue caused by Phaeoacremonium parasiticumIndian J Med Microbiol200927669

6 

G N Kumar S P Nair Phaeohyphomycosis presenting as a solitary nodulocystic lesion in a renal transplant patientIndian Dermatol Online J2015635961

7 

Sanjay G. Revankar Deanna A. Sutton Michael G. Rinaldi Primary Central Nervous System Phaeohyphomycosis: A Review of 101 CasesClin Infect Dis 2004382206216

8 

A Ziefer D H Connor Phaeomycotic cyst. A clinicopathologic study of twenty-five patientsAm J Trop Med Hyg19802990111

9 

S Tamboli S Agashe P Patil Phaeomycotic Cyst - A Case ReportIndian Med Gazette201141920

10 

S Balamurugan Rajsekar Ramesh Rao Subcutaneous phaeohypomycosisIndian J Pathol Microbiol 20095234545

11 

Natarajan Madhavan Manoharan Saveetha Shanmugam Veeriyan A rare case of a subcutaneous Phaeomycotic cyst with a brief review of literatureMalaysian J Med Sci2011187881

12 

Archana Shivamurthy Shaila Talengala Bhat Padmapriya Jaiprakash Subcutaneous phaeomycotic cyst: a case reportOur Dermatol Online2014532735

13 

R C Fader M R Mcginnis Infections caused by dematiaceous fungi: Chromoblastomycosis and phaeohyphomycosisInfect Dis Clin North Am292538

14 

L Ajello L K Georg R T Steigbigel C J Wang A case of phaeohyphomycosis caused by a new species of PhialophoraMycologia1974664908

15 

Salwa S. Sheikh Samir S. Amr Mycotic cysts: report of 21 cases including eight pheomycotic cysts from Saudi ArabiaInt J Dermatol200746438892

16 

Marcia Garnica Marcio Nucci Flavio Queiroz-Telles Difficult mycoses of the skin: advances in the epidemiology and management of eumycetoma, phaeohyphomycosis and chromoblastomycosisCurr Opin Infect Dis 200922655963

17 

Deepa Radhakrishnan G Jayalakshmi A Madhumathy SThasneem Banu S Geethalakshmi G Sumathi Subcutaneous phaeohyphomycosis due to Exophiala spinifera in an immunocompromised hostIndian J Med Microbiol 20102843969

18 

P J O'Donnell M S Hutt Subcutaneous phaeohyphomycosis: a histopathological study of nine cases from Malawi.J Clin Pathol 198538328892

19 

KKiran Kumar Kaveri Hallikeri PhaeohyphomycosisIndian J Pathol Microbiol 20085145568

20 

Kim Langfelder Martin Streibel Bernhard Jahn Gerhard Haase Axel A Brakhage Biosynthesis of fungal melanins and their importance for human pathogenic fungiFungal Genet Biol200338214358

21 

Joshua D. Nosanchuk Arturo Casadevall Impact of Melanin on Microbial Virulence and Clinical Resistance to Antimicrobial CompoundsAntimicrob Agents Chemother200650351928

22 

S G Revankar Dematiaceous fungi: Chromoblastomycosis, Mycetoma, Phaeohyphomycosis. Antimicrobe, Infectious diseases and Antimicrobial agents2009

23 

Ronen Ben‐Ami Russell E. Lewis Issam I. Raad Dimitrios P. Kontoyiannis Phaeohyphomycosis in a Tertiary Care Cancer CenterClin Infect Dis2009488103341

24 

B Aranegui C Feal C P García A Batalla T Abalde A M Martínez Subcutaneous phaeohyphomycosis caused by Exophiala jeanselmei treated with wide surgical excision and posaconazole: Case reportInt J Dermatol2013522556

25 

D A Sutton M G Rinaldi S E Sanche Dematiaceous J A Elias R M Michael Clinical mycologyChurchill Livingstone ElsevierNew York200934650

26 

M Kimura A Goto T Furuta T Satou S Hashimoto K Nishimura Multifocal Subcutaneous Phaeohyphomycosis Caused by Phialophora verrucosaArch Pathol Lab Med2003127913

27 

Nand Lal Sharma Vikram Mahajan Ramesh Chander Sharma Ashok Sharma Subcutaneous pheohyphomycosis in India - a case report and reviewInt J Dermatol 2002411620

28 

Y S Kumar N Kurian M Lawrence K Vimal S Teerthanath Rare Case of Fungal Osteoarthritis Caused by PhaeohyphomycosisJ Clin Diagn Res201268889

29 

Shawn Vasoo Lee Kien Yong Priyanka Sultania-Dudani Mary Lou Scorza Marin Sekosan Kathleen G. Beavis Phaeomycotic cysts caused by Phoma speciesDiagn Microbiol Infect Dis 201170531533



jats-html.xsl

© 2020 Published by Innovative Publication Creative Commons Attribution - NonCommercial 4.0 International (CC BY-NC 4.0) license (creativecommons.org)