Cutaneous Fusariosis in a Patient with Job's (Hyper-IgE) Syndrome

Abstract

Fusarium is a filamentous fungus that is ubiquitous in nature and can cause severe opportunistic infections in immunocompromised hosts. The association between Fusarium and hyper-IgE syndrome is exceedingly rare and has only been documented in a single report previously. A 44-year-old male, working as marijuana grower, with prior diagnosis of hyper-IgE syndrome and recurrent infections presented with enlarging right knee ulcer that did not respond to antimicrobial treatment. The patient was diagnosed with cutaneous fusariosis, confirmed with punch biopsy and positive wound cultures. The patient was managed with extended antifungal therapy (i.e., posaconazole) and surgical debridement resulting in remarkable improvement with wound healing leaving a pale scar. Fusarium should be considered in differential for cutaneous and invasive fungal infections in presence of cutaneous manifestations. Exposure to Cannabis plants is a noticeable risk factor. Multimodal approach involving systemic antifungals and wound debridement is essential for favorable outcome. Posaconazole was demonstrated to be a highly efficacious antifungal choice.

Figure 1

(a) Several scars on the patient's back resembling healing of old staphylococcal furunculosis; (b) distal subungual onychomycosis affecting multiple fingernails.

Figure 2

Ulcerative and necrotic lesion on the lateral aspect of the right knee measuring 7.5 × 6.0 × 0.1 cm. The wound base was mostly filled with eschar tissue with minimal granulation tissue.

Figure 3

Punch excision skin biopsy obtained from a right lower extremity ulcer. Digestive PAS stain demonstrating the presence of numerous fungal hyphae consistent with fungal infection. Gram stain appeared negative for bacterial organisms.

Figure 4

(a) Granulation tissue started to appear and serosanguineous discharge continued to show on the ulcer base (8.1 × 6.4 cm). (b) Progressive healing evidenced by hypergranulation with sloughing around the periphery (no serosanguinous discharge and no eschar tissue). (c) The size of the lesion had significantly reduced to 1.8 × 1.4 cm, and the wound healed completely leaving a pale and raised scar tissue at the site of the lesion.