BI28 Phaeohyphomycosis in the immunosuppressed patients: the challenges of treatment

Abstract

Abstract Phaeohyphomycosis is a group of multisystem mycoses owed to heterogeneous organisms called ‘dematiaceous’ or ‘melanized’ fungi. The presence of melanin in their cell walls is a distinguishing feature, likely to be acting as a virulence factor. Widely abundant in the environment, these organisms commonly infect humans through traumatic inoculation and have many clinical forms of presentation, including cutaneous, subcutaneous, systemic, and rarely disseminated. Both immunocompetent and immunocompromised hosts are affected. Diagnosis of the cutaneous infection is primarily reliant on histology and culture; treatment is not standardized and is based on clinical experience. We report a case of a 39-year-old man who presented to the dermatology clinic with ‘lumps’ on his lower limbs. His background included poorly controlled hypertension and diabetes mellitus type 2 leading to nephropathy and necessitating a renal transplant, which failed. A 5-year period of dialysis involving a sedentary lifestyle was followed by a repeat renal transplant during which time he developed multiple warty-looking nodules of varying size, with pseudomilia cysts on his lower limbs in addition to stasis changes. Histology reported a pigmented mould infection (probably phaeohyphomycosis), and there was no growth on culture. The patient was trialled on two azole antifungals at different times, but on both occasions, he dived into congestive cardiac failure needing intensive care unit admissions. Reducing immunosuppression therapy was difficult considering his previous failed renal transplant. Owing to the extent and multiplicity of the lesions on the background of immunosuppression, the surgical treatment option poses significant risks. Currently, he is managed on topical treatment with some stabilization of the lesions; however, it is unclear how these will progress in the future. Although uncommon, the number of patients with phaeohyphomycosis has increased due to awareness of melanized fungi on a background of the global COVID-19 pandemic, with SARS-CoV-2, and the use of immunosuppressive agents such as glucocorticoid therapy increasing the risk of infections of deep mycosis. Treatment for phaeohyphomycosis has largely been surgical excision for localized lesions in addition to oral antifungals. Our case highlights that, in transplant patients, therapeutics are difficult, with life-threatening complications from oral antifungals and the risks of surgical intervention including ulceration, bleeding and infections. In addition, the cosmetic appearance of the prevalent noticeable lesions for a relatively young patient is also significant and patient counselling is vital, especially when treatment options are minimal.