title: Melanized fungal infections in kidney transplant recipients: contributions to optimize clinical management.
abstract: OBJECTIVE
  This is a retrospective and observational study addressing clinical and therapeutic aspects of melanized fungal infections in kidney transplant recipients.
  
  
  METHODS
  We retrospectively reviewed medical records of all patients admitted between January 1996 and December 2013 in a single institution who developed infections by melanized fungi.
  
  
  RESULTS
  We reported on 56 patients aged between 30 and 74 years with phaeohyphomycosis or chromoblastomycosis (0.54 cases per 100 kidney transplants). The median time to diagnosis post-transplant was 31.2 months. Thirty-four (60.8%) infections were reported in deceased donor recipients. Fifty-one cases of phaeohyphomycosis were restricted to subcutaneous tissues, followed by two cases with pneumonia and one with brain involvement. Most dermatological lesions were represented by cysts (23/51; 45.1%) or nodules (9/51; 17.9%). Exophiala spp. (34.2%) followed by Alternaria spp. (7.9%) were the most frequent pathogens. Graft loss and death occurred in two patients and one patient, respectively. Regarding episodes of subcutaneous phaeohyphomycosis, a complete surgical excision without antifungal therapy was possible in 21 of 51 (41.2%) patients. Long periods of itraconazole were required to treat the other 30 (58.8%) episodes of subcutaneous disease. All four cases of chromoblastomycosis were treated only with antifungal therapy.
  
  
  CONCLUSIONS
  Melanized fungal infections should be considered in the differential diagnosis of all chronic skin lesions in transplant recipients. It is suggested that the impact of these infections on graft function and mortality is low. The reduction in immunosuppression should be limited to severely ill patients.
authors.affiliation: Special Mycology Laboratory-LEMI, Division of Infectious Diseases, Federal University of São Paulo, São Paulo, SP, Brazil; Division of Infectious Diseases, Hospital do Rim, São Paulo, SP, Brazil.
authors.forename: D W
authors.initials: DW
authors.lastname: Santos
authors.affiliation: Division of Infectious Diseases, Federal University of São Paulo, São Paulo, SP, Brazil.
authors.forename: L F
authors.initials: LF
authors.lastname: Camargo
authors.affiliation: Special Mycology Laboratory-LEMI, Division of Infectious Diseases, Federal University of São Paulo, São Paulo, SP, Brazil.
authors.forename: S S
authors.initials: SS
authors.lastname: Gonçalves
authors.affiliation: Department of Dermatology, Federal University of São Paulo, São Paulo, SP, Brazil.
authors.forename: M M
authors.initials: MM
authors.lastname: Ogawa
authors.affiliation: Department of Dermatology, Federal University of São Paulo, São Paulo, SP, Brazil.
authors.forename: J
authors.initials: J
authors.lastname: Tomimori
authors.affiliation: Department of Dermatology, Federal University of São Paulo, São Paulo, SP, Brazil.
authors.forename: M M
authors.initials: MM
authors.lastname: Enokihara
authors.affiliation: Division of Infectious Diseases, Hospital do Rim, São Paulo, SP, Brazil.
authors.forename: J O
authors.initials: JO
authors.lastname: Medina-Pestana
authors.affiliation: Special Mycology Laboratory-LEMI, Division of Infectious Diseases, Federal University of São Paulo, São Paulo, SP, Brazil; Division of Infectious Diseases, Federal University of São Paulo, São Paulo, SP, Brazil. Electronic address: arnaldolcolombo@gmail.com.
authors.forename: A L
authors.initials: AL
authors.lastname: Colombo
mesh_terms: D000328:Adult; D000368:Aged; D000528:Alternaria / Q000187:drug effects / Q000302:isolation & purification; D000935:Antifungal Agents / Q000627:therapeutic use; D002862:Chromoblastomycosis / Q000175:diagnosis* / Q000188:drug therapy*; D005093:Exophiala / Q000187:drug effects / Q000302:isolation & purification; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D017964:Itraconazole / Q000627:therapeutic use; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D060446:Phaeohyphomycosis / Q000175:diagnosis* / Q000188:drug therapy*; D012189:Retrospective Studies; D066027:Transplant Recipients
chemical_list: D000935:Antifungal Agents; D017964:Itraconazole
keywords: Chromoblastomycosis; Exophiala spp.; Kidney transplantation; Melanized fungi; Phaeohyphomycosis