title: Case of Paecilomyces lilacinus infection occurring in necrotizing fasciitis-associated skin ulcers on the face and surrounding a tracheotomy stoma.
abstract: A 28-year-old man undergoing treatment for hemophagocytic syndrome developed Paecilomyces lilacinus infection in skin ulcers on the face and in the tracheotomy stoma. While his bone marrow was suppressed by chemotherapy with dexamethasone, cyclosporin and etoposide for hemophagocytic syndrome, dental infection led to subacute necrotizing fasciitis caused by Pseudomonas aeruginosa on the right side of the face, resulting in a large area of soft tissue defects. Etoposide was discontinued, and prophylactic treatment with itraconazole was initiated. The ulcers resulting from necrotizing fasciitis were treated conservatively using trafermin and alprostadil alfadex ointment 0.003 %, and near-complete re-epithelialization occurred, except on the right lower eyelid, right buccal mucosa and perioral area. However, 6 weeks later, pustules/crusts started to form and break down repeatedly, leading to expansion of tissue defects on the face. Direct microscopic examination revealed fungal elements, and fungal culture identified Paecilomyces lilacinus suspicious twice some other day. Based on DNA extraction from the isolated fungus, this fungal strain was identified as Paecilomyces lilacinus. Cyclosporin and itraconazole were discontinued, and treatment with liposomal amphotericin B and a tapering dose of steroids was initiated. Cure was achieved in approximately 2.5 months after treatment initiation, and no relapse has been observed. The most important factor that ultimately contributed to the resolution of fungal infection might have been release of immunosuppression by discontinuing cyclosporin and tapering steroids.
authors.affiliation: Department of Dermatology and Plastic Surgery, Kumamoto University School of Medicine.
authors.forename: Eiko
authors.initials: E
authors.lastname: Nagamoto
authors.forename: Akihiko
authors.initials: A
authors.lastname: Fujisawa
authors.forename: Yuichiro
authors.initials: Y
authors.lastname: Yoshino
authors.forename: Kanako
authors.initials: K
authors.lastname: Yoshitsugu
authors.forename: Masashi
authors.initials: M
authors.lastname: Odo
authors.forename: Hidetaka
authors.initials: H
authors.lastname: Watanabe
authors.forename: Toshikatsu
authors.initials: T
authors.lastname: Igata
authors.forename: Hiromitsu
authors.initials: H
authors.lastname: Noguchi
mesh_terms: D000328:Adult; D000666:Amphotericin B / Q000008:administration & dosage; D000935:Antifungal Agents / Q000008:administration & dosage; D016572:Cyclosporine / Q000009:adverse effects; D003907:Dexamethasone / Q000009:adverse effects; D005145:Face; D019115:Fasciitis, Necrotizing / Q000209:etiology / Q000382:microbiology*; D006801:Humans; D007108:Immune Tolerance / Q000187:drug effects; D051359:Lymphohistiocytosis, Hemophagocytic / Q000150:complications / Q000188:drug therapy; D008297:Male; D009181:Mycoses / Q000188:drug therapy* / Q000209:etiology*; D010143:Paecilomyces; D011552:Pseudomonas Infections; D011550:Pseudomonas aeruginosa; D012883:Skin Ulcer / Q000188:drug therapy* / Q000209:etiology / Q000382:microbiology*; D054047:Surgical Stomas; D014140:Tracheotomy; D016896:Treatment Outcome
chemical_list: D000935:Antifungal Agents; D003907:Dexamethasone; D000666:Amphotericin B; D016572:Cyclosporine