Aim. To report a case of refractory fungal keratitis caused by Scedosporium apiospermum. Methods. Interventional case report. Results. A 47-year-old Malay housewife presented with left eye cornea ulcer as her first presentation of diabetes mellitus. There was no history of ocular trauma, contact lens used, or cornea foreign body. Scedosporium apiospermum was isolated from the cornea scrapping. Her cornea ulcer initially responded well to topical Amphotericin B within 3 days but subsequently worsened. Repeat cornea scrapping also yields Scedosporium apiospermum. This refractory keratitis was successfully treated with a combination of topical Amphotericin B and Voriconazole over 6 weeks. Conclusion. Scedosporium apiospermum keratitis is an opportunistic infection, which is difficult to treat despite tight control of diabetes mellitus and intensive antifungal treatment. The infection appeared to have very quick onset but needed long duration of treatment to completely heal. Surgical debridement always plays an important role as a therapeutic procedure as well as establishes the diagnosis through repeat scrapping.
Mycetoma is a chronic, granulomatous disease of the skin, and subcutaneous tissue, which sometimes involves muscle, bones, and neighboring organs. It is characterized by tumefaction, abscess formation, and fistulae with discharge of grains from sinuses. Mycetoma can be caused by various species of fungi (eumycetoma) and aerobic actinomycetes (actinomycetoma), which occur as saprophytes in soil or plants. A tentative diagnosis sufficient to initiate treatment may be made on the basis of grain color. For instance, melanoid grains are always caused by fungi and ochroid or pale grains by actinomycetes. Although this is not the thumbrule, there are exceptional reports too. As trauma favors infection, most lesions are on the foot and lower leg but they may occur anywhere on the body mimicking actinomycosis. However, lab investigations and culture are important tool to differentiate apart from the clinical picture. We are reporting atypical case with unusual site of presentation (perineum and thigh) of mycetoma.
Eumycetoma; melanoid; mycetoma
Pseudallescheria boydii has long been known to cause white grain mycetoma in immunocompetent humans, but it has recently emerged as an opportunistic pathogen of humans, causing potentially fatal invasive infections in immunocompromised individuals and evacuees of natural disasters, such as tsunamis and hurricanes. The diagnosis of P. boydii is problematic since it exhibits morphological characteristics similar to those of other hyaline fungi that cause infectious diseases, such as Aspergillus fumigatus and Scedosporium prolificans. This paper describes the development of immunoglobulin M (IgM) and IgG1 κ-light chain monoclonal antibodies (MAbs) specific to P. boydii and certain closely related fungi. The MAbs bind to an immunodominant carbohydrate epitope on an extracellular 120-kDa antigen present in the spore and hyphal cell walls of P. boydii and Scedosporium apiospermum. The MAbs do not react with S. prolificans, Scedosporium dehoogii, or a large number of clinically relevant fungi, including A. fumigatus, Candida albicans, Cryptococcus neoformans, Fusarium solani, and Rhizopus oryzae. The MAbs were used in immunofluorescence and double-antibody sandwich enzyme-linked immunosorbent assays (DAS-ELISAs) to accurately differentiate P. boydii from other infectious fungi and to track the pathogen in environmental samples. Specificity of the DAS-ELISA was confirmed by sequencing of the internally transcribed spacer 1 (ITS1)-5.8S-ITS2 rRNA-encoding regions of environmental isolates.
Scedosporium spp. are increasingly recognized as causes of resistant life-threatening infections in immunocompromised patients. Scedosporium spp. also cause a wide spectrum of conditions, including mycetoma, saprobic involvement and colonization of the airways, sinopulmonary infections, extrapulmonary localized infections, and disseminated infections. Invasive scedosporium infections are also associated with central nervous infection following near-drowning accidents. The most common sites of infection are the lungs, sinuses, bones, joints, eyes, and brain. Scedosporium apiospermum and Scedosporium prolificans are the two principal medically important species of this genus. Pseudallescheria boydii, the teleomorph of S. apiospermum, is recognized by the presence of cleistothecia. Recent advances in molecular taxonomy have advanced the understanding of the genus Scedosporium and have demonstrated a wider range of species than heretofore recognized. Studies of the pathogenesis of and immune response to Scedosporium spp. underscore the importance of innate host defenses in protection against these organisms. Microbiological diagnosis of Scedosporium spp. currently depends upon culture and morphological characterization. Molecular tools for clinical microbiological detection of Scedosporium spp. are currently investigational. Infections caused by S. apiospermum and P. boydii in patients and animals may respond to antifungal triazoles. By comparison, infections caused by S. prolificans seldom respond to medical therapy alone. Surgery and reversal of immunosuppression may be the only effective therapeutic options for infections caused by S. prolificans.
Mycetoma a worldwide disease frequently occurs in the tropics with the highest prevalence being in Africa. Madurella mycetomatis is the main causative organism of human eumycetoma in Sudan. The legs and feet were commonly the sites of the infection. A 22-year-old lady was presented with painful abdominal swelling around a previous caesarian section scar. A provisional diagnosis of obstructed incisional hernia was put. Histopathological examination revealed macroscopically four masses of soft tissue. Microscopic sections showed grains of Madurella mycetomatis.
Black-grain mycetomas are subcutaneous devastating chronic infections due to several dematiaceous fungi. They are diagnosed mostly in tropical countries. Identification of these fungi with standard mycological procedures is difficult because of their poor or delayed sporulation. The aim of this study was thus to assess the accuracy of molecular identification of these fungi. A total of 54 strains, mostly of clinical origin, were used, including 15 Madurella mycetomatis, 6 Madurella grisea, 12 Leptosphaeria senegalensis, 4 Leptosphaeria tompkinsii, 6 Pyrenochaeta spp., 4 Curvularia lunata, and 7 Exophiala jeanselmei strains. The internal transcribed spacer 1 (ITS1)-5.8S-ITS2 DNA region was amplified by using universal fungal primers and sequenced. Both intra- and interspecies sequence similarities were assessed. Madurella mycetomatis appeared to be a homogeneous species. More intraspecies variations were found for C. lunata and E. jeanselmei, leading, in some instances, to changes in the initial identification. L. senegalensis and L. tompkinsii showed intraspecies similarities of >99%, but similarity between the two species was <88%. Intergenera and interspecies variations were important, with sequence homologies of <81% between genera. In contrast, Pyrenochaeta romeroi and M. grisea appeared to be heterogeneous, with intraspecies similarities of 40 to 100% and 53 to 100%, respectively, which suggest either erroneous identification or the need for taxonomic revision. Epidemiological and therapeutic studies could benefit from a precise identification of the fungi responsible for black-grain mycetoma based not only on phenotypical characteristics but also on ITS sequencing.
Eumycetoma is a traumatic fungal infection in tropical and subtropical areas that may lead to severe disability. Madurella mycetomatis is one of the prevalent etiologic agents in arid Northeastern Africa. The source of infection has not been clarified. Subcutaneous inoculation from plant thorns has been hypothesized, but attempts to detect the fungus in relevant material have remained unsuccessful. The present study aims to find clues to reveal the natural habitat of Madurella species using a phylogenetic approach, i.e. by comparison of neighboring taxa with known ecology. Four species of Madurella were included in a large data set of species of Chaetomium, Chaetomidium, Thielavia, and Papulaspora (n = 128) using sequences of the universal fungal barcode gene rDNA ITS and the partial LSU gene sequence. Our study demonstrates that Madurella species are nested within the Chaetomiaceae, a family of fungi that mainly inhabit animal dung, enriched soil, and indoor environments. We hypothesize that cattle dung, ubiquitously present in rural East Africa, plays a significant role in the ecology of Madurella. If cow dung is an essential factor in inoculation by Madurella, preventative measures may involve the use of appropriate footwear in addition to restructuring of villages to reduce the frequency of contact with etiologic agents of mycetoma. On the other hand, the Chaetomiaceae possess a hidden clinical potential which needs to be explored.
Eumycetoma caused by Madurella mycetomatis is a common subcutaneous, mutilating fungal infection endemic in arid climate zones. Still there are many controversies on the route of infection, but traumatic inoculation of the subcutaneous tissue with the thorn or soil causative organism through minor skin trauma is a popular theory. This is due to the fact that, the origin and natural habitat of Madurella species, the prevalent mycetoma agents are still unknown. In order to predict the natural habitat of M. mycetomatis we investigated its phylogenetic relationships to species with known ecology. Two genes phylogeny based on LSU and ITS was performed for the species of the genus Madurella and representative genera from the family of Chaetomiaceae. Our findings confirmed that Madurella species are phylogenetically member of the family Chaetomiaceae. Members of this family are often found in dung and manure-enriched soil. We therefore suggest that animal dung, abundantly present in endemic villages, could be a possible niche for Madurella and plays an essential role in the onset of eumycetoma. This will help in understanding the origin of the disease and could be a base for future in depth study to investigate the presence of Madurella in dung from endemic areas.
Scedosporium apiospermum is part of the Pseudallescheria-Scedosporium complex. Peptidorhamnomannans (PRMs) are cell wall glycopeptides present in some fungi, and their structures have been characterized in S. apiospermum, S. prolificans and Sporothrix schenckii. Prior work shows that PRMs can interact with host cells and that the glycopeptides are antigenic. In the present study, three monoclonal antibodies (mAbs, IgG1) to S. apiospermum derived PRM were generated and their effects on S. apiospermum were examined in vitro and in vivo. The mAbs recognized a carbohydrate epitope on PRM. In culture, addition of the PRM mAbs increased S. apiospermum conidia germination and reduced conidial phagocytosis by J774.16 macrophages. In a murine infection model, mice treated with antibodies to PRM died prior to control animals. Thus, PRM is involved in morphogenesis and the binding of this glycopeptide by mAbs enhanced the virulence of the fungus. Further insights into the effects of these glycopeptides on the pathobiology of S. apiospermum may lead to new avenues for preventing and treating scedosporiosis.
The incidence of fungal infections has increased dramatically over the last 50 years, largely because of the increasing size of the population at risk, which especially includes immunocompromised hosts. Scedosporium apiospermum is a filamentous fungus that causes a variety of infections, ranging from localized disease to life-threatening disseminated infections. Glycoproteins are molecules present in the fungal surface and are comprised of carbohydrate and protein components. They are involved in different important functions in the fungal cell. Monoclonal antibodies can be used as therapeutic agents for infectious disease, but some factors involved in their efficacy are often not well understood. We found that monoclonal antibodies to glycoproteins present in fungal surface can be nonprotective and can even enhance the disease. The administration of these antibodies can affect functions of the fungal cell and the immune cells, resulting in a survival advantage for the fungus during interactions with the host.
Cranial eumycetoma (CE) due to direct inoculation of Madurella grisea into the scalp is extremely rare. We describe a case of CE caused by direct inoculation of M. grisea with the characteristic MRI findings of the “dot-in-circle” sign and a conglomeration of multiple, extremely hypointense “dots.”
“Dot-in-circle”; sign; eumycetoma; Madurella grisea; magnetic resonance imaging
We report a case of diabetic foot ulcer caused by Scedosporium apiospermum in a seventy year old male patient with uncontrolled diabetes. Scedosporium apiospermum, the asexual phase of Pseudallescheria boydii a fungus isolated from a variety of natural substrates throughout the world including soil, polluted water, sewage and manure of poultry and cattle. P.boydii is now recognized as a medically important opportunistic fungus. This case has been reported for its rarity.
Scedosporium apiospermum; Diabetic foot; Pseudoallescheria boydii
S. prolificans has become a major pathogen in immunocompromised patients.
Scedosporium apiospermum and S. prolificans are fungi of increasing clinical importance, particularly in persons with underlying diseases. We reviewed the records of 59 patients in Australia from whom Scedosporium spp. were isolated from June 30, 1997, through December 31, 2003. S. apiospermum was isolated predominantly from the respiratory tracts of 28 of 31 patients with underlying lung diseases and resulted in 2 infections and 1 death. The annual number of S. apiospermum isolates remained constant. S. prolificans was isolated from 28 patients only after November 1999. Eight patients with acute myeloid leukemia or hematopoietic stem cell transplants had invasive infection; 4 had fungemia and 6 died from infection. S. prolificans caused locally invasive infection in 2 immunocompetent patients and was found in the respiratory tract of 18 patients with underlying respiratory disease but did not cause fungemia or deaths in these patients. Scedosporium spp. showed distinct clinical and epidemiologic features.
Scedosporium prolificans; Scedosporium apiospermum; Australia; immunocompetence; immunocompromised host; fungemia; respiratory tract colonization; stem cell transplantation; organ transplantation; research
Eumycetoma is a chronic subcutaneous mycosis mainly caused by Madurella spp. Fusarium opportunistic infections in humans are often caused by Fusarium solani and Fusarium oxysporum. We report a case of eumycetoma by F. subglutinans, diagnosed by clinical aspect and culture, and confirmed by PCR sequencing. The patient was successfully treated with oral itraconazole. To our knowledge, this is the second report of human infection and the first case of mycetoma by Fusarium subglutinans.
Eumycetoma; Mycetoma; Fusarium subglutinans; Itraconazole
Mycetoma is a chronic and progressive subcutaneous granulomatous infection characterized by painless swelling and tumefaction, draining sinus tracts, and purulent discharge. The term eumycetoma is used to describe an infection caused by fungi, while an actinomycetoma is used to describe an infection caused by filamentous bacteria. An accurate identification of the pathogen plays a vital role in the treatment plan as well as a positive outcome for the patient. In this report, we present an elderly white female with an initial presentation of mycetoma masquerading as a squamous cell carcinoma. We also review microbiology, diagnostic modalities, and treatment for mycetoma.
Scedosporium apiospermum (Pseudallescheria boydii) is an emerging opportunistic filamentous fungus that causes serious infections in both immunocompetent and immunocompromised patients. To gain insight into the immunopathogenesis of infections due to S. apiospermum, the antifungal activities of human polymorphonuclear leukocytes (PMNs), mononuclear leukocytes (MNCs), and monocyte-derived macrophages (MDMs) against two clinical isolates of S. apiospermum were evaluated. Isolate SA54A was amphotericin B resistant and was the cause of a fatal disseminated infection. Isolate SA1216 (cultured from a successfully treated localized subcutaneous infection) was susceptible to amphotericin B. MDMs exhibited similar phagocytic activities against conidia of both isolates. However, PMNs and MNCs responded differently to the hyphae of these two isolates. Serum opsonization of hyphae resulted in a higher level of superoxide anion (O2−) release by PMNs in response to SA54A (amphotericin B resistant) than that seen in response to SA1216 (amphotericin B susceptible; P < 0.001). Despite this increased O2− production, PMNs and MNCs induced less hyphal damage to SA54A than to SA1216 (P < 0.001). To investigate the potential mechanisms responsible for these differences, hyphal damage was evaluated in the presence of antifungal oxidative metabolites as well as in the presence of a series of inhibitors and scavengers of antifungal PMN function. Mannose, catalase, superoxide dismutase, dimethyl sulfoxide, and heparin had no effect on PMN-induced hyphal damage to either of the two isolates. However, azide, which inhibits PMN myeloperoxidase activity, significantly reduced hyphal damage to SA1216 (P < 0.01) but not to SA54A. Hyphae of SA1216 were slightly more susceptible to oxidative pathway products, particularly HOCl, than those of SA54A. Thus, S. apiospermum is susceptible to antifungal phagocytic function to various degrees. The selective inhibitory pattern of azide with respect to hyphal damage and the parallel susceptibility to HOCl suggests an important difference in susceptibilities to myeloperoxidase products that may be related to the various levels of pathogenicity and amphotericin B resistance of S. apiospermum.
Eumycetoma is a chronic cutaneous and subcutaneous infection caused by various genera of fungi producing specific colored granules known as grains. A 45-year-old farmer presented clinically with a left foot mass with multiple discharging sinuses existing for last 3 years. Clinical and radiological findings suggested a diagnosis of chronic osteomyelitis with suspicion of tuberculosis. Imprints plus fine needle aspiration cytology (FNAC) smears exhibited distinct brown-black colonies of a fungus having branching and septate hyphae embedded in matrix like material against a mixed inflammatory background. Periodic acid Schiff (PAS) stain gave positive staining and subsequent fungal culture confirmed the cytological diagnosis and aided in species identification as Madurella mycetomatis. Thus, eumycetoma can precisely be diagnosed and confidently differentiated from similar conditions such as actinomycetoma by simple and inexpensive cytological techniques such as FNAC and imprint smears, employing routine May-Grünwald-Giemsa, Papanicolaou and simple PAS stains on cytological specimen, thus leading to rapid diagnosis for institution of correct treatment.
Eumycetoma; fine needle aspiration cytology; Madurella mycetomatis; actinomycetoma; culture
To describe the imaging appearance of Scedosporium apiospermum (S. apiosermum) endophthalmitis in an immunocompetent female who underwent high resolution magnetic resonance imaging (MRI) of the orbits and showed subchoroidal abscess on diffusion-weighted imaging.
We highlight utility of MRI sequences: diffusion-weighted imaging (DWI), apparent diffusion coefficient (ADC), fluid-attenuated inversion recovery (FLAIR), and contrast-enhanced magnetic resonance imaging (CE-MRI) in the detection of a subchoroidal abscess and characterization of the inflammatory change of the uveal tract. Vitreous culture grew S. apiospermum.
Fungal endophthalmitis is a rare but aggressive process. Clinically, it can mimic other disease entities such as neoplasm. To the best of our knowledge, this is the first case that describes the CT and MRI imaging findings of S. apiospermum endophthalmitis. We emphasize the use of DWI and ADC sequences in the detection of subchoroidal abscess.
Secosporidium apiospermum; endophthalmitis; subchoroidal abscess; magnetic resonance imaging; diffusion-weighted imaging; contrast-enhanced magnetic resonance imaging
Eumycetoma caused by Madurella mycetomatis is treated surgically and with high doses of ketoconazole. Therapeutic responses are poor, and recurrent infections are common. In search of therapeutic alternatives in the treatment of mycetoma, we determined the in vitro susceptibilities of M. mycetomatis isolates against caspofungin, anidulafungin, and micafungin. As a comparator fungus, Aspergillus fumigatus was used. Minimal effective concentrations (MECs) and MICs were assessed and compared to those of ketoconazole. M. mycetomatis isolates were not susceptible to the echinocandins.
A 51-year-old male was admitted in our institute following an episode of near-drowning. He later developed ventriculitis and cerebral ring-enhancing lesions. He died following a subarachnoid hemorrhage due to rupture of a mycotic aneurysm involving the right fetal posterior cerebral artery. Scedosporium apiospermum was isolated from the cerebrospinal fluid. Central nervous system invasion by S apiospermum may present insidiously in near-drowning patients and, therefore, requires a high index of suspicion. In cases with the characteristic cerebral ring-enhancing lesions and concomitant ventriculitis, treatment should be instituted while awaiting fungal culture. With this article we intend to alert neurologists, intensivists, and physicians to this near fatal infection, as early identification and prompt treatment with voriconazole may be life saving.
Fungal meningitis; near-drowning; Pseudallescheria boydii; Scedosporium apiospermum
Presently, therapy of eumycetoma in Sudan is still based on surgery combined with prolonged ketoconazole therapy. This usually results in a poor clinical outcome. To determine if posaconazole and terbinafine could offer better therapeutic alternatives, the in vitro susceptibilities of 34 Madurella mycetomatis strains were determined. It appeared that posaconazole was highly active against M. mycetomatis but terbinafine was only moderately active. Since posaconazole has an excellent safety profile, it might provide an important alternative in mycetoma therapy.
The purpose of this study is to report a case of endogenous endopthalmitis caused by Scedosporium apiospermum with a favorable outcome and review previously reported cases, their treatment regimens and outcomes.
An 83-year-old man with diabetes mellitus, no other immunocompromising risk factors, and a history of S. apiospermum endopthalmitis in the left eye developed endopthalmitis in the right eye. Within 72 h of presentation, he was treated with a pars plana vitrectomy and intravitreal voriconozole.
Vitreous cultures confirmed S. apiospermum. The patient responded to treatment, with a favorable outcome and full recovery of vision.
Recognition of S. apiospermum endopthalmitis and appropriate early intervention with pars plana vitrectomy and intravitreal voriconozole can lead to a favorable outcome with restoration of visual acuity.
Endogenous endopthalmitis; Scedosporium apiospermum
Madurella mycetomatis is the most common cause of human eumycetoma. The genus Madurella has been characterized by overall sterility on mycological media. Due to this sterility and the absence of other reliable morphological and ultrastructural characters, the taxonomic classification of Madurella has long been a challenge. Mitochondria are of monophyletic origin and mitochondrial genomes have been proven to be useful in phylogenetic analyses.
The first complete mitochondrial DNA genome of a mycetoma-causative agent was sequenced using 454 sequencing. The mitochondrial genome of M. mycetomatis is a circular DNA molecule with a size of 45,590 bp, encoding for the small and the large subunit rRNAs, 27 tRNAs, 11 genes encoding subunits of respiratory chain complexes, 2 ATP synthase subunits, 5 hypothetical proteins, 6 intronic proteins including the ribosomal protein rps3. In phylogenetic analyses using amino acid sequences of the proteins involved in respiratory chain complexes and the 2 ATP synthases it appeared that M. mycetomatis clustered together with members of the order Sordariales and that it was most closely related to Chaetomium thermophilum. Analyses of the gene order showed that within the order Sordariales a similar gene order is found. Furthermore also the tRNA order seemed mostly conserved.
Phylogenetic analyses of fungal mitochondrial genomes confirmed that M. mycetomatis belongs to the order of Sordariales and that it was most closely related to Chaetomium thermophilum, with which it also shared a comparable gene and tRNA order.
Madurella mycetomatis is the commonest cause of eumycetoma in Sudan and other countries in tropical Africa. Currently, the early diagnosis of mycetoma is difficult. In attempting to improve the identification of M. mycetomatis and, consequently, the diagnosis of mycetoma, we have developed specific oligonucleotide primers based on the sequence of the internal transcribed spacer (ITS) regions spacing the genes encoding the fungal ribosomal RNAs. The ITS regions were amplified with universal primers and sequenced, and then two sets of species-specific primers were designed which specifically amplify parts of the ITS and the 5.8S ribosomal DNA gene. The new primers were tested for specificity with DNA isolated from human mycetoma lesions and DNA extracted from cultures of M. mycetomatis reference strains and related fungi as well as human DNA. To study the genetic variability of the ITS regions of M. mycetomatis, ITS amplicons were obtained from 25 different clinical isolates and subjected to restriction fragment length polymorphism (RFLP) analysis with CfoI, HaeIII, MspI, Sau3AI, RsaI, and SpeI restriction enzymes. RFLP analysis of the ITS region did not reveal even a single difference, indicating the homogeneity of the isolates analyzed during the current study.
Scedosporium apiospermum is increasingly recognized as a cause of localized and disseminated mycotic infections in near-drowning victims.
We report the case of a 59-year-old Japanese woman who was a survivor of a tsunami in northeastern Japan and who had lung and brain abscesses caused by S. apiospermum. Initially, an aspergillus infection was suspected, so she was treated with micafungin. However, computed tomography scans of her chest revealed lung abscesses, and magnetic resonance images demonstrated multiple abscesses in her brain. S. apiospermum was cultured from her bronchoalveolar lavage fluid, and antimycotic therapy with voriconazole was initiated. Since she developed an increase in the frequency of premature ventricular contractions, an adverse drug reaction to the voriconazole was suspected. She was started on a treatment of a combination of low-dose voriconazole and liposomal amphotericin B. After combination therapy, further computed tomography scans of the chest and magnetic resonance images of her brain showed a demarcation of abscesses.
Voriconazole appeared to have a successful record in treating scedosporiosis after a near drowning but, owing to several adverse effects, may possibly not be recommended. Thus, a combination treatment of low-dose voriconazole and liposomal amphotericin B may be a safe and effective treatment for an S. apiospermum infection. Even though a diagnosis of scedosporiosis may be difficult, a fast and correct etiological diagnosis could improve the patient's chance of recovery in any case.
Mycetoma is a chronic granulomatous infection caused by environmental fungi or bacteria. It affects dermal and subcutaneous tissues, with putative contiguous extension to muscles or bones. While common in tropical and subtropical areas, mycetoma is rare in Europe.
We describe a case of Actinomadura meyerae osteitis in a 49-year-old Caucasian woman who suffered a tibia open fracture contaminated with hay; to the best of our knowledge the first case of autochthonous A. meyerae infection reported in France. The bacterium was cultivated from a bone biopsy. Following surgical osteosynthesis and six months of treatment with cotrimoxazole, our patient made a full recovery.
Our case report suggests that A. meyerae is a potential agent of wound infection in farm workers in contact with hay.
Patients on anti-TNFα therapy are at increased risk for rare opportunistic infections. Here we are reporting a case of Scedosporium apiospermum infection in a patient treated with anti-TNF for 5 years. Patients on anti-TNFα need close follow-up and clinicians should be suspicious for atypical infections in these immunocompromised hosts.
Scedosporium; anti-TNF therapy; immunocompromised