Unusual Presentation of Subcutaneous Phaeohyphomycosis by Alternaria alternate

Abstract

The Alternaria species are dematiaceous fungi. Human infection due to dematiaceous fungi is uncommon. Most reported cases of alternariosis have occurred in patients with immunodeficiency. The majority of cases were solid-organ transplantation recipients. Cutaneous alternariosis lesions are usually asymptomatic solitary nodules, plaques of ulcers or subcutaneous cysts. Here we report a case of a 77-year-old female who presented with hemorrhagic skin necrosis in right arm that had developed from hemorrhagic bullae. Her prior medical history included iatrogenic Cushing's syndrome, hypertension, interstitial lung disease and congestive heart failure. Following administration of itraconazole, her lesions improved.

Keywords: Alternaria; Phaeohyphomycosis.

Fig. 1. (A) Tender multiple ulceration and several hemorrhagic bullae with erythematous base on the right forearm area. (B) Diffuse subcutaneous swelling with reticular enhancement was noted. Swelling of dermis and the peripheral region is noted. These lesions show heterogenous signal intensity on both T1WI and T2WI without significant enhancement.

Fig. 2. Histological examination of a biopsy specimen from a right forearm. (A, B) Acute suppurative dermal inflammation with granulomatous inflammation (Hematoxylin & eosin stain, A: ×10, B: ×40). (C) Gomori-methenamine silver stain showed branched fungal hyphae (×400). (D) Fontana-Masson stain showed the presence of melanin pigment in the fungal wall (×400).