Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Art & Psychiatry
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Conference Oration
Conference Summary
Continuing Medical Education
Cosmetic Dermatology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
Editor Speaks
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Miscellaneous Letter
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News & Views
Observation Letter
Observation Letters
Original Article
Original Contributions
Pattern of Skin Diseases
Pediatric Dermatology
Pediatric Rounds
Presedential Address
Presidential Address
Presidents Remarks
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Study Letter
Study Letters
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapy Letter
Therapy Letters
View Point
What’s new in Dermatology
View/Download PDF

Translate this page into:

Case Report
doi: 10.4103/0378-6323.41371
PMID: 18583793

An association of Alternaria alternata and Scopulariopsis brevicaulis in cutaneous phaeohyphomycosis

V Anandan1 , V Nayak2 , S Sundaram3 , P Srikanth4
1 Department of Dermatology, Sri Ramachandra University, Porur, Chennai-600116, India
2 Department of Biotechnology, Rajalaxmi College of Engineering, Thandalam, Chennai-602 105, India
3 Department of Pathology, Sri Ramachandra University, Porur, Chennai-600116, India
4 Department of Microbiology, Sri Ramachandra University, Porur, Chennai-600116, India

Correspondence Address:
V Nayak
Department of Biotechnology, Rajalaxmi College of Engineering, Thandalam, Chennai-602 105
How to cite this article:
Anandan V, Nayak V, Sundaram S, Srikanth P. An association of Alternaria alternata and Scopulariopsis brevicaulis in cutaneous phaeohyphomycosis. Indian J Dermatol Venereol Leprol 2008;74:244-247
Copyright: (C)2008 Indian Journal of Dermatology, Venereology, and Leprology


Rare molds are increasingly emerging as a cause of deep and invasive fungal infections. We report here a rare case of cutaneous phaeohyphomycosis of the lower limbs due to Alternaria alternata associated with extra-ungual localization of Scopulariopsis brevicaulis. Diagnosis was made based on repeated, direct, microscopic mycological and histological examinations. The study revealed hyphae and fungal cells in a granulomatous dermal infiltrate. Identification of the molds was based on macroscopic appearance on culture of samples from the lesions on Sabouraud's dextrose agar and microscopic appearance on Lactophenol cotton blue following slide culture.
Keywords: Alternaria alternate, Deep fungal infection, Phaeohyphomycosis, Scopulariopsis brevicaulis


Fungal pathogens, some previously unknown or considered saprophytes, are increasingly identified not only in solid organ recipients but also in other immunocompromised patients. The changing patterns of immunosuppressive agents, complex surgical techniques, artificial devices and the advent of acquired immunodeficiency syndrome (AIDS) have all contributed to the intrinsic risk for such fungal infections. [1],[2]

Alternaria, a common fungus found in the environment, is one of the causative agents of phaeohyphomycosis, usually caused by dematiaceous fungi. Although the genus comprises a large number of saprophytic and plant pathogenic species, only a few of these are implicated in human diseases namely, A. alternata , A. infectoria , A. tenuissima , and A. chartarum. Their importance as opportunistic pathogens is increasing among immunocompromised patients, especially in transplant recipients. [3] Clinically, they are more often encountered as traumatic mycoses. Scopulariopsis spp. are common soil saprophytes and have been isolated from a wide variety of substrates. They are dermatomycotic molds and have been mainly associated with onychomycosis. We present a rare case of cutaneous phaeohyphomycosis caused by Alternaria alternata and Scopulariopsis brevicaulis in an apparently immunocompetent individual. This case is being reported to heighten the awareness among clinicians of the atypical presentations of fungi of low virulence.

Case History

A 37 year-old female presented to us with complaints of multiple, raised skin lesions over both extremities for the past 20 days associated with fever and difficulty in walking. No definitive history of trauma could be elicited from the patient. She was not a known diabetic, hypertensive or asthmatic and gave no history of long-term therapy with any immunosuppressive drugs such as steroids.

Local examination revealed multiple, erythematous, indurated nodules over both lower limbs with necrosis and areas of hyperemia. A discharging sinus was present over the left leg [Figure - 1]A, B. The nails of the right hand and the toenails were dystrophic while the nails of the left hand were normal. Systemic examination did not reveal any abnormality. Liver and renal function tests and blood sugar levels were normal. Investigations revealed a raised total leukocyte count of 16,900 cells/mm 3 with 77% neutrophils and a hemoglobin level of 10.7g%. Screening tests for human immunodeficiency virus (HIV) infection and hepatitis B infection were negative. A chest X-ray (CXR) and an ultrasonogram (USG) of the abdomen were taken to rule out malignancy. However, neither the USG nor the CXR showed any abnormality. No further tests could be done to rule out immunosuppression.

Specimens were collected from the affected area, including the discharge from the sinus and sent for microbiological examination. A deep skin biopsy was taken and sent for histopathological examination. Periodic acid Schiff (PAS) and Gomori′s methenamine silver stain confirmed the fungus showing broad, septate, branching hyphal forms and large spores - both free and within the cytoplasm of giant cells [Figure - 2]A, B. Histopathologic examination indicated the presence of fungi; however, it was not possible to use tissue stains to differentiate the fungi based on their appearance.

Wet mounts of samples sent for mycological examination revealed numerous, brownish, septate hyphae and ovoid structures. Culture on Sabouraud′s Dextrose agar [SDA] with chloramphenicol showed gray-white colonies of Alternaria spp. with a dark brown pigment on the undersurface. Slide culture and microscopic observation using lactophenol cotton blue [LPCB] stain for identification of the fungus, revealed hyphae with typical conidia which were ellipsoidal with a short cylindrical beak, rugose with muriform septation showing transverse and longitudinal septa and a single scar at the tip. The conidia were arranged in long chains [Figure - 3].

Repeatedly collected and cultured samples from the affected site grew both fungi. Identification of the second fungus, Scopuloriopsis brevicaulis, was done by macroscopic appearance as whitish, felt-like colonies on culture, which later became pinkish-brown with the reverse color of creamish to brown. Both the slide culture technique and lactophenol cotton blue mount showed chains of single-celled annelloconidia (ameroconidia) produced in basipetal succession following a series of short, percurrent proliferations (annellations) by a specialized conidiogenous cell called an annellide. The conidia were rough-walled with a truncated base [Figure - 4]. A diagnosis of Alternaria alternata associated with Scopulariopsis brevicaulis infection was made based on histopathological and mycological examination.

The patient was initially treated with systemic steroids followed by antifungal agents - itraconazole and terbinafine. The patient appeared to improve after beginning antifungal therapy. However, she developed electrolyte imbalance and her vitals began to fluctuate. She was transferred to the intensive care unit. As her oxygen saturation also decreased, she was placed on a ventilator. Her condition however deteriorated over a period of time and she was discharged against medical advice, on the request of her relatives. She subsequently died at home.


Phaeohyphomycosis caused by Alternaria alternata may be difficult to recognize because lesions are variable in size and aspect, ranging from crusted lesions to erythematous macules or subcutaneous nodules. Cutaneous and subcutaneous deep tissue infections due to Alternaria species tend to occur most often in immunosuppressed patients, especially in organ transplant recipients. [2],[3],[4],[5],[6] Most of the clinical presentations were localized skin infections resulting from direct, traumatic inoculation, even if systemic spread is possible in a compromised host. [1],[2] The clinical presentation of multiple, erythematous, indurated purpuric nodules over both lower limbs in our case was atypical.

Onychomycosis is most often caused by dermatophytes. Other agents such as yeasts and nondermatophytic molds (NDMs) may cause onychomycosis as well. Historically, NDMs have largely been discounted as mere contaminants, especially when a dermatophyte was present concurrently. The dual etiology of the lesion may account for its atypical manifestation. As scopulariopsis may be associated with deep fungal infection, the invasive property of the fungus may account for the rapid deterioration of this patient. [7]

Scopulariopsis brevicaulis has rarely been reported as a cause of deep fungal infections. We believe that the implantation of this fungus in the extra-ungual site probably occurred due to scratching. Tosti et al. reported patients with a typical, distal, subungual onychomycosis characterized by subungual hyperkeratosis and onycholysis of the distal nail plate. [8] In addition, some isolates of S. brevicaulis have been demonstrated to be pathogenic in murine models of disseminated infection. [9] It should be noted that cutaneous mycoses caused by such fungi, are characterized by brownish hyphal elements in tissue, whereas subcutaneous mycoses often consist of large, hyaline, yeast-like cells. The production of melanin-like pigment is one of the major characteristics of this mould.

This case is being reported to heighten the awareness among clinicians of the atypical presentations of fungi of low virulence. The association of these two fungi is rare, especially in a case of cutaneous phaeohyphomycosis. The emergence of less common but medically important fungal pathogens contributes to diagnostic dilemmas, especially when accompanied by atypical manifestations. Early recognition of the lesion and treatment with appropriate antifungal therapy is essential to reduce morbidity and mortality.

Vartivarian SE, Anaissie EJ, Bodey GP. Emerging fungal pathogens in immunocompromised patients: Classification, diagnosis, and management. Clin Infect Dis 1993;17: 487-91.
[Google Scholar]
Jeorge AE, Claudine PF, Gerald PE. Onychomycosis and keratomycosis caused by Alternaria Sp: A bipolar opportunistic infection in a wood-pulp worker on chronic steroid therapy. Am J Dermatol 1996;18:611-3.
[Google Scholar]
Myser P, Nilles M, de Hoog GS. A Case report: Cutaneous Phaeohyphomycosis due to Alternaria alternata . Mycoses 2002;45:338-40.
[Google Scholar]
Merino E, Banulus J, Boix V, Franco A, Guijarro J, Portilla J, et al. Relapsing cutaneous alternariosis in a kidney transplant recipient cured with liposomal amphotericin B. Eur J Clin Microbiol Infect Dis 2003;22:51-3.
[Google Scholar]
Gilmour Tk, Rytina E, O'Connel PB, Sterling JC. Cutaneous alternariosis in a cardiac transplant recipient. Australas J Dermatol 2001;42:46-9.
[Google Scholar]
Acland KM, Hay RJ, Groves R. Cutaneous infection with Alternaria alternata complicating immunosuppression: Successful treatment with itraconazole. Br J Dermtol 1998;138:354-6.
[Google Scholar]
Tosti A, Piraccini BM, Lorenzi S, Iorizzo M Treatment of nondermatophyte mold and Candida onychomycosis. Dermatol Clin 2003;21:491-7.
[Google Scholar]
Tosti A, Piraccini BM, Stinchi C, Lorenzi S. Onychomycosis due to Scopulariopsis brevicaulis : Clinical features and response to systemic antifungals. Br J Dermtol 1996;135:802.
[Google Scholar]
Kwon-Chung KJ, Bennett JE. Infections due to miscellaneous molds. In : Kwon-Chung KJ, Bennett JE, edtors. Medical mycology. 1992. p. 733-67.
[Google Scholar]

Fulltext Views

PDF downloads
Show Sections