title: Cutaneous phaeohyphomycosis in a hematopoietic stem cell transplant patient caused by Alternaria rosae: First case report.
abstract: Alternaria species have been reported as a rare cause of fungal infection in organ and stem cell transplant recipients, but to date, no reports have been published of infection in humans caused by Alternaria rosae. Here, we report cutaneous A. rosae infection in a 66-year-old farmer with a history of primary myelofibrosis who had undergone allogeneic unrelated donor hematopoietic stem cell transplantation. Forty-nine days post transplant, he presented with a nodule on the thumb with no findings suggestive of disseminated infection. Pathology, culture, and molecular speciation showed the nodule was caused by cutaneous A. rosae. He had been on voriconazole as antifungal prophylaxis, but was found to have a subtherapeutic voriconazole level. He was switched to posaconazole based on published in vitro data showing its superior efficacy in Alternaria treatment. Susceptibility testing showed that the A. rosae isolate was indeed susceptible to posaconazole. His cutaneous lesion remained stable, but he died from respiratory failure secondary to lobar pneumonia. At lung autopsy, A. rosae was not identified in the lungs. We believe this to be the first published report, to our knowledge, of A. rosae infection in humans.
authors.affiliation: Division of General Internal Medicine, University of Washington, Seattle, WA, USA.
authors.forename: Amy W
authors.initials: AW
authors.lastname: Liu
authors.affiliation: Department of Laboratory Medicine, University of Washington, Seattle, WA, USA.
authors.forename: Allen C
authors.initials: AC
authors.lastname: Bateman
authors.affiliation: Division of Hematology, University of Washington, Seattle, WA, USA.|Division of Medical Oncology, University of Washington, Seattle, WA, USA.
authors.forename: Adam
authors.initials: A
authors.lastname: Greenbaum
authors.affiliation: Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA.
authors.forename: Kanishka
authors.initials: K
authors.lastname: Garvin
authors.affiliation: Department of Laboratory Medicine, University of Washington, Seattle, WA, USA.|Pathology and Laboratory Medicine Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.
authors.forename: Jill
authors.initials: J
authors.lastname: Clarridge
authors.affiliation: Division of Medical Oncology, University of Washington, Seattle, WA, USA.|Hospital and Specialty Medicine, Medical Oncology Section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.|Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Grim
mesh_terms: D058186:Acute Kidney Injury / Q000139:chemically induced / Q000628:therapy; D000212:Acyclovir / Q000627:therapeutic use; D000368:Aged; D000528:Alternaria / Q000302:isolation & purification / Q000472:pathogenicity*; D060487:Alternariosis / Q000382:microbiology*; D019072:Antibiotic Prophylaxis / Q000379:methods; D000935:Antifungal Agents / Q000627:therapeutic use*; D004359:Drug Therapy, Combination / Q000009:adverse effects / Q000379:methods; D017809:Fatal Outcome; D006086:Graft vs Host Disease / Q000188:drug therapy; D006225:Hand / Q000000981:diagnostic imaging; D018380:Hematopoietic Stem Cell Transplantation / Q000009:adverse effects*; D006801:Humans; D007165:Immunosuppression Therapy / Q000009:adverse effects / Q000379:methods; D064704:Levofloxacin / Q000627:therapeutic use; D008279:Magnetic Resonance Imaging; D008297:Male; D008826:Microbial Sensitivity Tests; D010256:Paranasal Sinuses / Q000000981:diagnostic imaging; D060446:Phaeohyphomycosis / Q000382:microbiology*; D011014:Pneumonia / Q000150:complications; D011241:Prednisone / Q000627:therapeutic use; D055728:Primary Myelofibrosis / Q000628:therapy*; D012131:Respiratory Insufficiency / Q000150:complications; D013172:Spores, Fungal / Q000302:isolation & purification / Q000472:pathogenicity; D014184:Transplantation, Homologous / Q000009:adverse effects; D014230:Triazoles / Q000627:therapeutic use; D065819:Voriconazole / Q000627:therapeutic use
chemical_list: D000935:Antifungal Agents; D014230:Triazoles; D064704:Levofloxacin; C101425:posaconazole; D065819:Voriconazole; D011241:Prednisone; D000212:Acyclovir
keywords: 
  Alternaria rosae
  ; cutaneous; hematopoietic stem cell transplantation; immunosuppression; posaconazole; voriconazole