Subcutaneous phaeohyphomycosis in transplant recipients: review of the literature and demonstration of in vitro synergy between antifungal agents

Infection of subcutaneous tissue by black fungi (subcutaneous phaeohyphomyc osis) has only been reported in six transplant patients, all of whom were s olid organ recipients. These patients presented with indolent, localized in fections at least 1 year after transplant, while on maintenance immunosuppr essive regimens. They were cured by surgical resection, either alone or in conjunction with antifungal agents. We report a case of subcutaneous phaeoh yphomycosis occurring in a bone marrow transplant recipient receiving high doses of immunosuppressive agents, in whom widespread subcutaneous infectio n due to Exophiala jeanselmei was not eradicated by repeated resections and therapy with amphotericin B and flucytosine. The infection was eventually cured after addition of itraconazole to the therapeutic regimen. Results of in vitro testing of the isolate for susceptibility to a combination of amp hotericin B, flucytosine and itraconazole confirmed the potential role of c ombination antifungal therapy in the setting of refractory infection.