title: Clinical Characteristics, Diagnosis, Management, and Outcomes of Disseminated Emmonsiosis: A Retrospective Case Series.
abstract: BACKGROUND
  We describe the geographic distribution, clinical characteristics, and management of patients with disease caused by Emmonsia sp., a novel dimorphic fungal pathogen recently described in South Africa.
  
  
  METHODS
  We performed a multicenter, retrospective chart review of laboratory-confirmed cases of emmonsiosis diagnosed across South Africa from January 2008 through February 2015.
  
  
  RESULTS
  Fifty-four patients were diagnosed in 5/9 provinces. Fifty-one patients (94%) were human immunodeficiency virus coinfected (median CD4 count 16 cells/µL [interquartile range, 6-40]). In 12 (24%) of these, antiretroviral therapy had been initiated in the preceding 2 months. All patients had disseminated disease, most commonly involving skin (n = 50/52, 96%) and lung (n = 42/48, 88%). Yeasts were visualized on histopathologic examination of skin (n = 34/37), respiratory tissue (n = 2/4), brain (n = 1/1), liver (n = 1/2), and bone marrow (n = 1/15). Emmonsia sp. was cultured from skin biopsy (n = 20/28), mycobacterial/fungal and aerobic blood culture (n = 15/25 and n = 9/37, respectively), bone marrow (n = 12/14), lung (n = 1/1), lymph node (n = 1/1), and brain (n = 1/1). Twenty-four of 34 patients (71%) treated with amphotericin B deoxycholate, 4/12 (33%) treated with a triazole alone, and none of 8 (0%) who received no antifungals survived. Twenty-six patients (48%) died, half undiagnosed.
  
  
  CONCLUSIONS
  Disseminated emmonsiosis is more widespread in South Africa and carries a higher case fatality rate than previously appreciated. Cutaneous involvement is near universal, and skin biopsy can be used to diagnose the majority of patients.
authors.affiliation: Departments of Medical Microbiology and Internal Medicine, Faculty of Health Sciences, College of Medicine, University of Manitoba, Winnipeg, Canada Department of Epidemiology and Social Medicine, Faculty of Health Sciences, University of Antwerp, Belgium.
authors.forename: Ilan S
authors.initials: IS
authors.lastname: Schwartz
authors.affiliation: National Institute for Communicable Diseases-Centre for Opportunistic, Tropical and Hospital Infections, National Health Laboratory Service, Sandringham Faculty of Health Sciences, University of the Witwatersrand, Johannesburg.
authors.forename: Nelesh P
authors.initials: NP
authors.lastname: Govender
authors.affiliation: Ampath National Laboratory Services, Centurion.
authors.forename: Craig
authors.initials: C
authors.lastname: Corcoran
authors.affiliation: Division of Infectious Diseases & HIV Medicine, Department of Medicine, University of Cape Town.
authors.forename: Sipho
authors.initials: S
authors.lastname: Dlamini
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Stellenbosch University.
authors.forename: Hans
authors.initials: H
authors.lastname: Prozesky
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Stellenbosch University.
authors.forename: Rosie
authors.initials: R
authors.lastname: Burton
authors.affiliation: Division of Infectious Diseases & HIV Medicine, Department of Medicine, University of Cape Town.
authors.forename: Marc
authors.initials: M
authors.lastname: Mendelson
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Stellenbosch University.
authors.forename: Jantjie
authors.initials: J
authors.lastname: Taljaard
authors.affiliation: Division of Dermatology, Department of Medicine, University of Cape Town.
authors.forename: Rannakoe
authors.initials: R
authors.lastname: Lehloenya
authors.affiliation: UCT Lung Institute, University of Cape Town, South Africa.
authors.forename: Greg
authors.initials: G
authors.lastname: Calligaro
authors.affiliation: Department of Epidemiology and Social Medicine, Faculty of Health Sciences, University of Antwerp, Belgium Clinical Sciences Unit, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Robert
authors.initials: R
authors.lastname: Colebunders
authors.affiliation: Division of Infectious Diseases & HIV Medicine, Department of Medicine, University of Cape Town Clinical Sciences Unit, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Chris
authors.initials: C
authors.lastname: Kenyon
mesh_terms: D000328:Adult; D000935:Antifungal Agents / Q000627:therapeutic use*; D001706:Biopsy; D002912:Chrysosporium / Q000302:isolation & purification*; D005260:Female; D006801:Humans; D008297:Male; D009181:Mycoses / Q000175:diagnosis* / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D015995:Prevalence; D012189:Retrospective Studies; D012867:Skin / Q000382:microbiology* / Q000473:pathology*; D013019:South Africa / Q000453:epidemiology; D016019:Survival Analysis; D016896:Treatment Outcome
chemical_list: D000935:Antifungal Agents
keywords: AIDS-related mycosis; Emmonsia sp.; dimorphic fungi; emmonsiosis; endemic mycosis