A 68-year-old Brazilian male patient presented at the Hand Pathology Service of the Hospital de São Paulo with a purple nodule measuring 2-3 cm in diameter on the left dorsum.
The lesions were painless and of fibro-elastic consistency.
He did not report other symptoms.
As a history, the patient had undergone a kidney transplant 35 months before the appearance of the lesions and was under continuous treatment with tacrolimus (7 mg/day), azathioprine (50 mg/day) and prednisone (10 mg/day).
The patient did not report any trauma, however, his profession was gardener so he could have acquired this mycosis of implantation for his work with plants.
Both lesions were surgically removed without any other treatment.
The material was sent to the Mycology Special Laboratory (LEMI) of the Federal University of São Paulo for histopathological and histological examination.
The staining with hematoxylin-eosin, Gomori and vesicular-Masson revealed the presence of dematiaceous hyphae in both lesions and was later identified as A. infectoria.
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A year later, the patient had another nodule, this time in the 5th phalanx of the right hand.
Biopsy and culture of the lesion were performed, and C. gloeosporioides was isolated.
The patient was on a lower dose of tacrolimus (3 mg/day), but with azathioprine and prednisone at the same doses.
The patient had suffered some local trauma, but a new entity frequently worked in his garden.
Complete surgical excision of the lesion was performed without antifungal treatment.
After one year of follow-up no new lesions were observed.
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Mycological study
Infectious disease
Biopsies were performed using Sabouraud agar (SDA) and potato agar (PDA), where colonies of gray-to-olive color were observed, with a tertile-shaped appearance.
Micromorphology showed the presence of fleshy conidiophores, dark brown color, non-branched, with ovoid conidia, rough, with apical extension often very short or oblic origin.
The agent was identified as A. infectoria.
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Colletotrichum gloeosporioides
Fungal colonies obtained from biopsy material and nodule aspirate were inoculated in potato dextrose agar (PDA) and inoculated at room temperature.
The colonies grew rapidly, presenting a grey tonality to coffee, with rosacea spots.
On the reverse, it was brown.
In the micromorphology were observed straight, cylindrical, hyaline and obtuse in the apex.
In addition, there are numerous cells called apresoria with a claviciform or irregular appearance, with dark pigment.
Hysterosis was identified as C. gloporioides.
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Antifungal susceptibility testing
Although the cut-off points for the definition of antifungal susceptibility against melanoma have not been established, we chose to perform susceptibility tests.
There is evidence in the literature that MIC values ≤ 1 μg/mL against most antifungals are related to a good therapeutic response.
In addition, knowledge of the etiologic agent and susceptibility profile of isolates in immunocompromised patients is important because they can cause serious infections with dissemination to other organs and systems
Susceptibility testing was performed using the broth microdilution technique, according to the CLSI philosophies document M38A13.
Susceptibility results are presented in Table 1.
C. gloeosporioides strain showed low MIC for amphotericin B and voriconazole and high MIC for 5-fluorcytosine and fluconazole.
Moreover, the A. infectoria strain was resistant to the five antifungals used.
