Increased Incidence of Invasive Fusariosis with Cutaneous Portal of Entry, Brazil

Marcio Nucci

, Andrea G. Varon, Marcia Garnica, Tiyomi Akiti, Gloria Barreiros, Beatriz Moritz Trope, and Simone A. Nouér

Author affiliations: University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil

Abstract

Invasive fusariosis (IF) is an infection with Fusarium spp. fungi that primarily affects patients with hematologic malignancies and hematopoietic cell transplant recipients. A cutaneous portal of entry is occasionally reported. We reviewed all cases of IF in Brazil during 2000–2010, divided into 2 periods: 2000–2005 (period 1) and 2006–2010 (period 2). We calculated incidence rates of IF and of superficial infections with Fusarium spp. fungi identified in patients at a dermatology outpatient unit. IF incidence for periods 1 and 2 was 0.86 cases versus 10.23 cases per 1,000 admissions (p<.0.001), respectively; superficial fusarial infection incidence was 7.23 versus 16.26 positive cultures per 1,000 superficial cultures (p<.0.001), respectively. Of 21 cases of IF, 14 showed a primary cutaneous portal of entry. Further studies are needed to identify reservoirs of these fungi in the community and to implement preventive measures for patients at risk.

Invasive fusariosis (IF) is a mycosis caused by infection with Fusarium spp. fungi that affects primarily patients with hematologic malignancies and hematopoietic cell transplant (HCT) recipients (1,2). In these severely immunosuppressed patients, IF is typically disseminated and involves pneumonia, metastatic skin lesions, and positive blood cultures (3). The usual portal of entry is the airways, and IF is thought to be acquired by the inhalation of aerosols of fusarial conidia. However, the skin at sites of tissue breakdown may be a portal of entry (4). In a review of 232 published cases of IF in immunosuppressed patients, primary skin lesions represented the likely portal of entry in 16 (11%) of 147 patients with disseminated disease (5).
In 2007, we observed an increase in the incidence of IF in our hospital in Brazil: 5 cases of disseminated IF and 2 cases of locally invasive disease were diagnosed in a 7-month period. In addition to this apparent increase in incidence, we observed that all patients had a primary skin lesion on the lower limbs. All case-patients were housed in 4 rooms of the hematology unit. Because of the increasing incidence and the cutaneous primary lesions, environmental sampling of air, water, and water-related structures of the hematology unit were conducted; we also performed molecular analysis of patient and environmental isolates. We describe the incidence, clinical presentation, and outcome of these cases and compare these results with cases of superficial Fusarium spp. infection among outpatient dermatologic patients at the same hospital.