Scedosporium infection is rarely encountered in clinical practice, but it encompasses a clinically wide range of diseases, some of them being severe and life-threatening. It is primarily diagnosed in immunocompromised patients and the three most common forms are post-traumatic subcutaneous infection, asymptomatic or symptomatic colonization and disseminated infection. The diagnosis can be made by various microbiological methods, the most reliable being PCR, whereas surgical debridement and voriconazole are recommended as therapeutic strategies.
The clinical presentation of patients with Scedosporium infection encompasses numerous forms. A broad classification recognizes three distinct clinical entities   :
- Localized disease after trauma - This type, unlike other forms, is more commonly seen in immunocompetent individuals who develop an infection after skin trauma that allows the fungus to invade local tissues. As a result, several forms may develop. Mycetoma is a chronic, suppurative inflammation of subcutaneous and bone tissue and is one of the most common clinical presentations of Scedosporidium. In most cases, a small, hard, painless nodule develops on the lower limbs, most commonly the feet, which ulcerates over time and releases purulent fluid. If untreated, significant morbidity due to further involvement of adjacent tissues can occur . Arthritis is another clinical subtype that often presents with minimal or no symptoms; the knee and elbow joints may be infected by Scedosporidium and cause chronic inflammation. Endophthalmitis, osteomyelitis, otomycosis and lymphocutaneous syndrome are amongst other recognized forms of localized disease.
- Colonization of cavities - Sinusitis, otitis, pulmonary fungus ball and allergic bronchopulmonary Scedosporium pneumonia (ABSP) occur as a result of Scedosporium inhalation into the upper respiratory tract and its subsequent invasion into local cavities. These syndromes may be either asymptomatic or symptomatic, in which case typical features such as epistaxis, facial edema, pallor, earache that may progress to tympanic membrane rupture and asthma-like symptoms may be reported, respectively .
- Systemic invasive disease, most commonly in the form of pneumonia, is a severe and life-threatening infection that occurs as a result of local fungal invasion and cough, hemoptysis, weight loss, fatigue, dyspnea and respiratory failure are its reported symptoms . Apart from respiratory infection, disseminated disease, endocarditis and CNS infection , can also be caused by Scedosporium.
Entire Body System
By day 2 of medical therapy, the patient's fever cleared and the edema and diplopia resolved. On the seventh day of medical treatment, there were no ocular signs or symptoms. [jamanetwork.com]
We present a case of renal allograft recipient who developed fever two weeks post renal transplant. He was initially found to have dengue fever. After five days, he became drowsy and developed right-sided hemiparesis. [sjkdt.org]
→ improved Ko et al, 38 1999 52/male Taiwan AIDS Fever, diarrhea, anemia, abdominal pain 3 weeks Yes Cecum Ulcer Amphotericin B and itraconazole → improved Ko et al, 38 1999 30/male Taiwan AIDS Dyspepsia, diarrhea, fever, abdominal pain, LGIB, weight [ncbi.nlm.nih.gov]
Because of graft rejection, the patient received a second transplantation 35 days after the first one, at which time he had a high fever and abdominal pains. [onlinelibrary.wiley.com]
- Weight Loss
An antifungal treatment with voriconazole was started, but one month later, in reason of no amelioration on CT control and persistence of fever and weight loss, a surgical approach was decided. [aspergillus.org.uk]
She denied fever, weight loss, chest pain, or shortness of breath. She had no prior medical history, had no prior lung infections, and took no medications. [atsjournals.org]
[…] al, 48 2010 39/female Peru None Diarrhea, abdominal pain, fever, weight loss 2 months Yes Whole colon Ulcer Amphotericin B → died Leon et al, 49 2010 34/male Peru None Diarrhea, oral ucers, odynophagia, weight loss, cough 18 months Yes Whole colon Ulcer [ncbi.nlm.nih.gov]
She complained of dyspnea, weight loss (25 kg in 10 months), anorexia and weakness. [scielo.br]
A 21-year-old woman with Wegener granulomatosis treated with prednisone and cyclophosphamide developed fever, myalgias, malaise, and headache with stiff neck. [jamanetwork.com]
Van Calck et al, 29 1988 47/male Belgium AIDS Hematochezia, fever Not mentioned Yes Perirectum Perirectal abscess Surgery, amphotericin B and flucytosine → improved Daly et al, 30 1990 63/male USA Cirrhosis, splenectomy, corticosteroids Fever, chills, malaise [ncbi.nlm.nih.gov]
Aug 1st, 2019 - Panayiotopoulos syndrome (PS) is a frequent (6% among children of 1-15 years) and benign epileptic syndrome, characterized by predominantly autonomic symptoms (emesis, pallor, flushing, cyanosis, mydriasis/miosis, cardiorespiratory and [allmedx.com]
- Exposure to Contaminated Water
Aeromonas spp. naturally thrive in fresh and brackish waters and have been isolated in humans in wound and gastrointestinal infections after exposure to contaminated water. [hindawi.com]
Colonization of the respiratory tract with S. apiospermum is usually asymptomatic in patients with cystic fibrosis.  It causes Scedosporium pneumonia in systemic invasive disease. [ijpmonline.org]
Aeromonas spp. have been described most often in near-drowning pneumonia cases. [hindawi.com]
Initial results revealed Haemophilus influenzae and Streptococcus pneumoniae in the lavage sample. [atsjournals.org]
Here we present a case of disseminated S. apiospermum infection with cutaneous manifestations in a 59-year-old woman with myelodysplastic syndrome, in remission from chronic lymphocytic leukemia, presented with pneumonia and deteriorating mental status [ncbi.nlm.nih.gov]
Case presentation: A 35-year-old female with CF, with a 1-month history of irritating cough, increased sputum production and dyspnoea, was admitted to hospital. [microbiologyresearch.org]
He gave the history of cough with expectoration and breathlessness on exertion on and off for the past 1 year. He had a past history of pulmonary tuberculosis 6 years ago. [ijpmonline.org]
Her cough and night sweats initially improved on antibiotics but returned 3 days after discontinuation, prompting presentation to our hospital. On arrival, her vital signs were normal. [atsjournals.org]
This is a case of invasive lung infection due to S. apiospermum who presented with hemoptysis. [ijpmonline.org]
Cough was the most common presentation (60.0%), followed by hemoptysis or blood-tinged sputum (50.0%) and fever (35.0%). Duration of symptoms ranged from hours to 9 years. [journals.lww.com]
Fifteen days later, the patient developed a temperature of 38°C, chest pain, and hemoptysis. WBC count was 14,900 cells/mm 3 (93% neutrophils), and other analytical parameters were within normal limits. [academic.oup.com]
Indications for Surgical Removal of Tissue Infected with Hyalohyphomycosis · Hemoptysis from a single cavitary lung lesion (always perform a computerized chest scan to search for other lesions). · Progressive cavitary lung lesion (always perform a computerized [antimicrobe.org]
She complained of dyspnea, weight loss (25 kg in 10 months), anorexia and weakness. [scielo.br]
[…] lesions and invasive disease, simulating aspergillosis. ,  Sinusitis may present in both immunocompetent and immunocompromised patients with variable severity.  As the clinical presentation of Scedosporium infection, including fever, cough, and dyspnea [e-ijd.org]
A 75-year-old woman with severe asthma, who was receiving low-dose maintenance corticosteroid therapy, was admitted to our institution because of increasing dyspnea, tachypnea, and nonproductive cough. [academic.oup.com]
Co-trimoxazole → improved Chojniak et al, 46 2000 57/not mentioned Brazil None Abdominal pain, diarrhea, weight loss 2 years No Cecum Mass Ketoconazole → not mentioned Costa Vieira et al, 47 2001 60/male Brazil None Fever, perianal nodule, dysphonia, cough, dyspnea [ncbi.nlm.nih.gov]
Clinical symptoms were mostly associated with the site of fungal infection, e.g., neurological symptoms were seen on 10/11 children (91%) with CNS infection and pulmonary signs such as chest pain, dyspnea and cough in 10/15 patients (67%) with lung involvement [ijidonline.com]
- Sputum Production
Case presentation: A 35-year-old female with CF, with a 1-month history of irritating cough, increased sputum production and dyspnoea, was admitted to hospital. [microbiologyresearch.org]
Rheumatoid arthritis and reactive arthritis were suspected as the etiology for joint pain. [e-ijd.org]
Subcutaneous infections, osteomyelitis, and arthritis are usually posttraumatic and may affect otherwise healthy individuals. [drfungus.org]
Arthritis, osteomyelitis, eye infections and onychomycosis are the other localized diseases. [ijpmonline.org]
- Knee Pain
However, a day after stopping ECMO, the patient developed a fever and complained of blurred vision in the right eye and knee pain. B-scan ultrasonography of the eye suggested infective endophthalmitis ( Figure 2 ). [journals.sagepub.com]
Case Report A 45-year-old male, resident of Noida, Uttar Pradesh, presented to a tertiary care hospital with complaints of swelling, excessive watering, redness, pain, and photophobia in the right eye for 3 days. [cjhr.org]
It presents itself in a form of painful lesions within the retina accompanied by symptoms like photophobia and blurred vision. Disseminated mycosis Severely immunocompromised patients, patients on immunosuppressive therapy, as well as those suffering [en.wikipedia.org]
- Corneal Infiltrate
The affected eye revealed severe conjunctival congestion and corneal ulcer of 3 mm × 4 mm in size along with corneal infiltrates. Right eyelid gaping was also observed. [cjhr.org]
He had a 4 x 4 mm central corneal infiltrate with satellite lesions and a 4 mm hypopyon ( Figure 1a ). Figure 1(a): Anterior segment exam revealing scleritis with overlying tutoplast and corneal ulcer with hypopyon. [omicsonline.org]
- Eye Pain
- Conjunctival Injection
Examination showed conjunctival injection, vitritis, a yellow-white preretinal mass over the temporal macula, and a flocculent whitish vitreous mass in the inferotemporal macula. [jamanetwork.com]
- Skin Lesion
Many erythematous, indurated skin lesions, measuring 3-5 mm in diameter, were noted on her chest, shoulders and arms. Biopsies were submitted for culture and histology. [ncbi.nlm.nih.gov]
On physical examination, multiple nodular skin lesions were present on the dorsal aspect of both hands and forearms. Most of the nodules were ulcerated, with intermittent oozing of serous fluid. [ijdvl.com]
Chen Sir, We describe a case of scedosporiosis in a 76-year-old farmer who consulted us for painless, multiple, nodular skin lesions on the extensor surface on both his forearms for 6 months. [go.gale.com]
Her vision deteriorated, and skin lesions appeared on the right arm and left hip. Results of peripheral blood and cutaneous and pulmonary biopsy cultures were negative. [jamanetwork.com]
A 57-year-old immunosuppressed patient presented with multiple erythematous papules and pustules as well as isolated ulcerations on the right lower leg and subcutaneous nodules on the right thigh. [infona.pl]
A physical examination revealed a 4 x 3 cm, poorly defined, erythematous papule, which was fluctuant, with pustules and crusts on the dorsum of the left hand. [bmcinfectdis.biomedcentral.com]
It can commonly be found on the surface of the skin in a form of white and yellow papules. [en.wikipedia.org]
- Skin Ulcer
Chaetoconidium and atypical acid-fast bacilli in skin ulcers. Arch Dermatol 1972;106:875-876. [PubMed] 44. Madrigal V, Alonso J, Bureo E, Figols FJ, Salesa R. [antimicrobe.org]
Three weeks later, her orbital cellulitis resolved; however, she developed nausea, vomiting, headaches, left vision loss, diplopia, and local pain. [hindawi.com]
The authors present a 73-year-old woman with chronic renal disease who presented with headache for 2 weeks. Computerized tomography scans revealed a ring-enhancing lesion in left temporal lobe. [revistaneurocirugia.com]
[…] manustatakse teie lapsele annuses # mg/kg kehakaalu kohta üks kord kuus senikaua, kui on oht RSV infektsiooni tekkeks en For subjects who received Cubicin, the adverse reactions that were most frequently reported during therapy plus follow-up were: headache [et.glosbe.com]
Two weeks later he developed bifrontal headache, with features suggestive of raised intracranial pressure. Examination showed neck stiffness and a positive Kernig sign, without other focal neurological deficits. [annalsofian.org]
To confuse things even further, S. apiospermum has yet another asexual coremial form called Graphium eumorphum, syn. Graphium fructicola, but is usually reported as the "Graphium state of Scedosporium apiospermum." [emlab.com]
Unfortunately, two months later the patient presented again with fevers and confusion, and his CSF cultures grew Scedosporium apiospermum. [hindawi.com]
Forty days after admission, a transient episode of mental confusion with disorientation developed and a magnetic resonance imaging (MRI) scan of the brain was performed. [asianjns.org]
Abstract Favorites PDF Get Content & Permissions Open Translation and validation of the Tibetan confusion assessment method for the intensive care unit Danzeng, Qu-Zhen; Cui, Na; Wang, Hao; More Chinese Medical Journal. 132(10):1154-1158, May 20, 2019 [cmj.org]
Scedosporium spp. can be differentiated by their more irregular branching pattern compared to the orderly dichotomous 45-° angle branching observed in Aspergillus and by their production of ovoid conidia with truncated bases, which can be confused with [ncbi.nlm.nih.gov]
Six weeks into the illness, he developed recurrent seizures and a repeat computerized tomography (CT) of the brain showed a subarachnoid hemorrhage (SAH) involving the basal cisterns and cortical sulci; extending to the occipital horns, third and fourth [annalsofian.org]
[…] amphotericin B and flucytosine → improved Daly et al, 30 1990 63/male USA Cirrhosis, splenectomy, corticosteroids Fever, chills, malaise 7 days Yes Transverse colon Mass Amphotericin B and flucytosine → died Bonacini et al, 31 1990 31/male USA AIDS Hemiplegia, seizure [ncbi.nlm.nih.gov]
Surgical drainage is imperative before starting drug therapy. » Case Presentation A 72-year-old male without any comorbidities presented with complaints of sudden onset, left-sided limb weakness for four days, and history of a generalized tonic-clonic seizure [neurologyindia.com]
- Focal Neurological Deficit
Examination showed neck stiffness and a positive Kernig sign, without other focal neurological deficits. [annalsofian.org]
It involves the CNS in 50% of invasive disease cases, with brain abscess being the main pathology with or without associated meningitis. The usual location of abscess is cerebral hemispheres, brainstem, cerebellum, and spinal cord causing focal neurological [neurologyindia.com]
In all patients, a thorough patient history that may identify previous trauma or an underlying disease that predisposes to opportunistic infections and a meticulous physical examination should be performed, followed by imaging procedures including plain radiography or computed tomography (CT) in the setting of a soft-tissue or pulmonary infection. Although Scedosporium is rarely encountered in clinical practice, its under -recognition must be taken into consideration, especially in the frequent presence of competing flora such as Aspergillus and Candida which often leads to misinterpretation of microbiological findings . Nevertheless, it is imperative to obtain a valid sample for investigation, whether it is bronchoalveolar lavage (BAL), cerebrospinal fluid (CSF), blood or sample of the skin. Culture is a reliable method to identify Scedosporium, although direct microscopy and staining, as well as histopathological examination, are also mentioned as possible diagnostic procedures . PCR, however, is a rapid diagnostic test that can provide results much faster than culture and had equal specificity, which is why it should be performed whenever possible. It is of essential to determine the organism responsible for the symptoms, because antimicrobial therapy may significantly differ from one species to the another.
The genus Scedosporium includes, but is not limited to, three species that cause life-threatening infections in humans: Scedosporium apiospermum, Scedosporium prolificans (recently renamed Lomentospora prolificans), and Scedosporium aurantiacum . [hindawi.com]
Scedosporium endophthalmitis: two fatal disseminated cases of Scedosporium infection presenting with endophthalmitis. Clin Exp Ophthalmol. 2001;29(5):330–4. [link.springer.com]
H Disseminated infection by Scedosporium prolificans: an emerging fatality among haematology patients. [journalofinfection.com]
The physiological properties of Scedosporium have also been explored for use as a diagnostic tool to differentiate it from similar species such as Scedosporium prolificans. [cjhr.org]
After the isolation of Scedosporium the patient was treated with itraconazole for 4weeks as Scedosporium is almost always resistant to amphotericin. [ijpmonline.org]
In the case of localized infection after trauma, surgical debridement is by far the most important therapeutic modality, while administration of antifungal drugs is the mainstay of managing symptomatic colonization and systemic infections . Reports have shown that Scedosporium sp. are universally resistant to amphotericin B, fluconazole, ketoconazole and even to itraconazole and miconazole  . These results significantly limit the number of options regarding antifungal therapy, leading to the selection of voriconazole as first-line therapy according to current guidelines . 6 mg/kg either PO or V q12g on the first day, followed by 4 mg/kg either PO or IV q12h is the recommended regimen . As an alternative therapy, posaconazole in doses of 400 mg PO q12h taken during meals is suggested . For this reason, it is necessary to perform susceptibility testing after identification of Scedosporium in patient samples, so that optimal therapy can be given.
The outcome of infection significantly depends on the status of the immune system of the individual, the severity of infection and the site of involvement . Unfortunately, S. prolificans is normally resistant to available antifungal agents, and mortality rates in isolated reports range between 70-100% for S. apiospermum and S. prolificans, respectively . For these reasons, an early identification of the microorganism is essential in order to initiate therapy as soon as possible.
Scedosporidium sp. is an emerging cause of infection in immunocompromised hosts. Two principal species responsible for the infection have been described - S. apiospermum and S. prolificans. Under the microscope, these filamentous fungi show greyish-white, fast growing colonies and a greyish-black reverse, while their mycelium is colorless . The natural habitat for Scerosporodium sp. is yet to be determined, but it was isolated from soil, plants, mud and various poorly aerated areas with low oxygen concentrations,and also from various animals such as horses, dogs and cats and animal excretions (bats, chickens and bird feces)  . Additionally, studies that have described nosocomial outbreaks show that contaminated air-conditioning systems and buildings under construction may also be a source of this filamentous fungus .
Infection by Scedosporium is reported in countries where levels of humidity are high, including Canada, United States, Germany, France, the Netherlands, Spain , and also Australia, where the percentage of less common mold infections was surprisingly high . Incidence rates in single-center studies have shown a slight increase in the number of cases, rising from 0.82 per 100,000 in the 1990s to 1.33 cases per 100,000 patient-inpatient days at the beginning of the 21st century . The opportunistic nature of S. apiospermum is shown by the fact that it is a well-known cause of death in transplant recipients, with an established incidence rate of 1 in 1000 patients . As reports state that the majority of infections were acquired by inhalation and the respiratory route, preexisting lung disease, such as cystic fibrosis (CF) has shown to be a significant risk factor for Scedosporium infection . In fact, between 10-20% of CF patients yield positive sputum samples for this filamentous fungus . Severe pulmonary infections were also recognized in a very small number of individuals who experienced near-drowning accidents after aspirating polluted water and sewage .
The pathogenesis model in the case of Scedosporidium infection is not completely clear. The first step of invasion is colonization of the human host, either by inoculation of the skin after breaks due to trauma or inhalation and colonization of the upper respiratory tract. In either setting, the main defense system against filamentous fungi are polymorphonuclear leukocytes and monocytes, collectively known as macrophages, involving both oxidative and non-oxidative reactions . It was established that cytokines such as interleukin-15 (IL-15) play an important role in the mobilization of immune cells . However, studies have determined that alveolar macrophages phagocytose and eliminate Scedsporidium hyphae much less efficiently than other filamentous fungi, for e.g. Aspergillus, suggesting that other factors play a role in limiting the potency of the immune system to eliminate this fungus . So far, the most prominent candidate is alpha-glucan, a glycogen-like polysaccharide located on the Scedosporidium hyphae, which was shown to be one of the key elements in induction of cytokines and phagocytosis . One of the main reasons why immunocompromised individuals are at a much higher risk for this infection, especially those suffering from neutropenia, is the insufficient activity of the monocyte-macrophage system, leading to a favorable environment for the fungus to grow, replicate, invade local tissues and disseminate through hematogenous routes to distant sites .
Management of the underlying condition that causes immunosuppression can be considered as a preventive strategy . This may not be easy, however, since bone marrow and solid organ recipients must be on intensive immunosuppressive therapy, which is why antifungal prophylaxis was recommended by some authors, but infections have developed despite adequate prophylactic administration of antifungal therapy, thus questioning this strategy in reducing incidence of Scedosporium infections . Due to the extensive presence of these filamentous fungi in nature and the fact that their natural habitat is unknown, prevention of their inhalation or inoculation onto the skin is currently impossible.
The two Scedosporium species - Sp. prolificans and Sp. apiospermum (also known as the asexual form of Pseudallescheria boydii), are rare but emerging causes of infection in various countries of the world including Europe, North America and Australia . Scedosporium sp. are considered to be opportunists, meaning that they almost exclusively cause infections in immunocompromised individuals, most frequently those receiving heavy corticosteroid therapy for bone marrow or solid organ transplant . Patients suffering from cystic fibrosis (CF) were shown to be at a particular risk for this infection, as Scedosporium was found in up to 10-20% of sputum samples in certain reports . The pathogenesis model somewhat varies depending on the type of infection, but various host factors, as well as the degree of fungal virulence determine the course of the disease . On the basis of its acquisition, there are three main forms - localized disease after trauma (such as mycetoma, arthritis and osteomyelitis, which can occur in immunocompetent individuals as well); colonization of cavities (sinusitis, otitis and pulmonary colonization that may be either symptomatic or asymptomatic); and systemic disease (pneumonia, endocarditis, meningitis and disseminated disease) that may be life-threatening if not recognized early on  . Because of a diverse clinical presentation that may involve virtually any organ or site on the body, a proper microbiological workup that includes identification of the underlying microorganism is vital. Various tests have been proposed (cultivation, serology), but because of its similarity to several other fungal organisms, the most reliable method for detection of Scedosporium in patient samples is detection of DNA through polymerase chain reaction (PCR) testing . Treatment principles somewhat vary depending on the type of infection. Surgical debridement is recommended in subcutaneous and localized infections, while antifungal therapy is the mainstay of cavity colonization and systemic infections. One of the main issues in treating Scedsporidium is a very high rate of antifungal resistance and current guidelines suggest voriconazole as first-line therapy because all other agents are ineffective. The prognosis of patients is determined by the severity of infection, status of the immune system and treatment efficacy, but it is essential to recognize and confirm this microorganism early, as systemic infections are quite commonly life-threatening and fatal, especially those involving the central nervous system .
Scedosporium infection is a rare but sometimes life-threatening disease and is caused by two fungi - Scedosporidium apiospermum and S. prolificans, microorganisms that are ubiquitously present in nature. They are not only found in soil, polluted waters, plants, but also in the excretory products of various animals.They are considered opportunistic pathogens as they primarily cause disease in individuals who have a disease which weakens their immune system. Use of immunosuppressive therapy in bone marrow or solid organ recipients, chemotherapy for cancer and human immunodeficiency virus (HIV) infection are some clinical circumstances in which patients are predisposed to this infection. Studies show that Scedosporium is rarely encountered in medical practice, but countries all over the world including Spain, Germany, United States, Canada and Australia have reported patients in whom this infection was confirmed. Scedosporium may present in myriad forms and three main entities have been described: local infection after previous skin trauma that allowed inoculation of fungi into the subcutaneous tissue; colonization of sinuses or the lungs that may be either asymptomatic or symptomatic; and systemic disease in the form of pneumonia (lung infection), endocarditis (infection of the heart valves), meningitis (infection of the central nervous system) or disseminated infection. Local infection of the skin and subcutaneous tissues may be seen in otherwise healthy and immunocompetent individuals, whereas colonization of the respiratory tract and subsequent infection of internal organs is restricted to immunocompromised patients. For this reason, the appearance of the disease is closely related to the status of the patient's immune system. To make the diagnosis, it is necessary to obtain a sample from the patient that is suitable for microbiological investigation (blood, cerebrospinal fluid, piece of skin, or sputum) and various tests are used for confirmation. Treatment principles are surgical debridement in the case of local infection and administration of antifungal drugs in other types of infection. Unfortunately, Scedosporium species are resistant to the majority of drugs currently used in therapy and voriconazole is currently one of the few agents that is effective against this fungus. With early therapy, the prognosis of patients is very good, but mortality rates in severe infections are very high, rising up to 100% in central nervous system infection, which is why early recognition of the disease is essential in reducing the burden of this infection.
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