Scedosporiosis – MD Nexus

Mycology

Scedosporium Apiospermum Complex is a Fungus Which is Ubiquitously Found in the Environment (Including in the Soil and Polluted Water)

Scedosporium Apiospermum Complex Infection May Be Associated with Aspiration in the Setting of Near Drowning (see Near Drowning, Near Drowning)
Scedosporium Apiospermum Complex Consists of Several Distinct Species: importantly, the distinct species may have unique susceptibility patterns
- Pseudallescheria Apiosperma (Anamorph Scedosporium Apiospermum)
  - Scedosporium Apiospermum is the Asexual Form (Anamorph) of Pseudallescheria Boydii
- Pseudallescheria Boydii (Scedosporium Boydii)
- Pseudallescheria Minutispora
- Scedosporium Aurantiacum
  - Scedosporium Aurantiacum Has Been Isolated from the Human Respiratory Tract
  - Most Cases Have Been Reported in Australia in Association with Chronic Lung Disease (and Less Commonly, Invasive Disease)
- Scedosporium Dehoogii
Scedosporium Apiospermum Complex is Globally Distributed in Europe, Australia, South America, and the United States
Human Infection Occurs Via Inhalation of Spores into the Lungs or Paranasal Sinuses or Via Direct Inoculation into a Wound (Skin Puncture)
- Hospital-Acquired Infections May Occur Via Contaminated Air in Ventilation Systems

Physiology

Significance of Scedosporium Apiospermum Complex Airway Colonization

Scedosporium Apiospermum Complex Airway Colonization in Cystic Fibrosis (CF) Patients (see Cystic Fibrosis, Cystic Fibrosis)

Scedosporium Apiospermum Complex is the Second Most Common Filamentous Fungus Isolated from the Airways of Patients with Cystic Fibrosis
- Fungus May Be an Inflammatory Stimulus, Similar to Aspergillus in Allergic Bronchopulmonary Aspergillosis (ABPA)
- Possible Risk Factors for Scedosporium Apiospermum Complex Airway Colonization in Cystic Fibrosis
  - Allergic Bronchopulmonary Aspergillosis (ABPA) (see Allergic Bronchopulmonary Aspergillosis, Allergic Bronchopulmonary Aspergillosis)
  - Presence of Bacterial/Fungal Co-Colonizers
  - Use of Antimicrobial Agents
Scedosporium Aurantiacum Airway Colonization Has Also Been Reported in Patients Cystic Fibrosis in Europe (France, Germany) and Australia (Med Mycol, 2010) [MEDLINE] (Med Mycol, 2013) [MEDLINE] (PLoS One, 2017) [MEDLINE]

Scedosporium Apiospermum Complex Airway Colonization in Lung Transplant Patients (see Lung Transplant, Lung Transplant)

Airway Colonization (Including Cystic Fibrosis Patients) Prior to Lung Transplant May Increase the Risk of Invasive Infection After Lung Transplant (Transpl Infect Dis, 2014) [MEDLINE] (Transpl Infect Dis, 2017) [MEDLINE]: such patients may benefit from azole antifungal therapy before/after transplantation

Diagnosis

Serum (1,3)-β-D-Glucan (see Serum (1–3)-β-D-Glucan, Serum (1-3)-β-D-Glucan)

May Be Helpful, But Has Not Been Validated in the Diagnosis of Scedosporiosis

Pathology

All Hyaline Molds Appear Similar by Microscopic Examination with Sepated, Nonpigmented Hyphae and 45 Degree Angle Branching
- Hyaline Molds
  - Acremonium (see Acremonium, Acremonium)
  - Aspergillus (see Aspergillus, Aspergillus)
  - Fusarium (see Fusarium, Fusarium)
  - Lomentospora (see Lomentospora Prolificans, Lomentospora Prolificans)
  - Paecilomyces (see Paecilomyces, Paecilomyces)
  - Scedosporium
- Culture is Required to Distinguish the Species

Clinical Manifestations

General Comments

Scedosporium Apiospermum Complex is Predominantly Associated with Infection in Immunocompromised Hosts
- However, Localized Infections Have Been Reported in Immunocompetent Hosts

Cardiovascular Manifestations

Endocarditis (see Endocarditis, Endocarditis)
- Epidemiology
  - Case Has Been Reported in a Cardiac Transplant Patient (Med Mycol Case Rep, 2015) [MEDLINE]

Dermatologic Manifestations

Skin Infection
- Epidemiology
  - Occurs in the Setting of Disseminated Infection
- Clinical
  - Bullae (see Vesicular-Bullous-Pustular Skin Lesions, Vesicular-Bullous-Pustular Skin Lesions)
  - Erythematous-Purple Papules or Nodules (see Papular-Nodular Skin Lesions, Papular-Nodular Skin Lesions)
    - May Have a Necrotic Center
    - Signs of Lymphangitic Spread May Be Observed in Some Cases

Hematologic Manifestations

Lymphadenitis (see Lymphadenopathy, Lymphadenopathy)
- Epidemiology
  - May Occur in Immunocompetent Hosts

Neurologic Manifestations

Brain Abscess (see Brain Abscess, Brain Abscess)
- Epidemiology
  - May Occur in Immunocompetent/Immunocompromised Hosts
  - Cases Have Been Reported Following Near Drowning Episodes
- Physiology
  - In Near Drowning Episodes, Portal of Entry May Be the Sinuses with Contiguous Spread or the Lung with Hematogenous Dissemination
  - In Immunocompromised Hosts (Hematopoietic Stem Cell Transplants, Solid Organ Transplants), Hematogenous Dissemination is the Predominant Mode of Spread to the Brain
- Clinical
  - Agitation (see Agitation, Agitation)
  - Altered Mental Status (see Altered Mental Status, Altered Mental Status)
  - Cognitive Deficits
  - Fever (see Fever, Fever)
  - Headache (see Headache, Headache)
  - Hemiparesis (see Weakness, Weakness)
  - Seizures (see Seizures, Seizures)

Ophthalmologic Manifestations

Endogenous Endophthalmitis (see Endophthalmitis, Endophthalmitis)
- Physiology
  - Due to hHmatogenous Dissemination in an Immunocompromised Host
- Diagnosis
  - Funduscopic Examination (see Funduscopic Examination, Funduscopic Examination): hazy vitreous, exudates
- Clinical
  - Decreased Visual Acuity
  - Eye Pain (see Eye Pain, Eye Pain)
  - Photophobia (see Photophobia, Photophobia)
Keratitis (see Keratitis, Keratitis)
- Epidemiology
  - May Occur in Immunocompetent Host with/without Ocular Trauma/Injury
- Clinical
  - Conjunctival/Corneal Erythema (see Conjunctival Injection, Conjunctival Injection)
  - Decreased Visual Acuity
  - Eye Pain (see Eye Pain, Eye Pain)
  - Foreign Body Sensation
  - Photophobia (see Photophobia, Photophobia)
  - Tearing
  - Complications
    - Anterior Chamber Hypopyon
    - Corneal Abrasion
    - Corneal Perforation
    - Corneal Ulcer

Otolaryngologic Manifestations

Sinusitis (see Acute Rhinosinusitis, Acute Rhinosinusitis)
- Epidemiology
  - Occurs in Immunocompromised Hosts

Pulmonary Manifestations

Pneumonia (see Pneumonia, Pneumonia)
- Risk Factors
  - Chronic Corticosteroid Use (see Corticosteroids, Corticosteroids)
  - Chronic Granulomatous Disease (CGD) (see Chronic Granulomatous Disease, Chronic Granulomatous Disease)
  - Hematologic Malignancy
    - Acute Lymphocytic Leukemia (ALL) (see Acute Lymphocytic Leukemia, Acute Lymphocytic Leukemia)
    - Acute Myeloid Leukemia (AML) (see Acute Myeloid Leukemia, Acute Myeloid Leukemia)
  - Hematopoietic Stem Cell Transplant (HSCT) (see Hematopoietic Stem Cell Transplant, Hematopoietic Stem Cell Transplant)
  - Solid Organ Transplant
    - Cardiac Transplant (see Cardiac Transplant, Cardiac Transplant)
    - Cardiac-Lung Transplant (see Cardiac-Lung Transplant, Cardiac-Lung Transplant)
    - Liver Transplant (see Liver Transplant, Liver Transplant)
    - Lung Transplant (see Lung Transplant, Lung Transplant)
    - Renal Transplant (see Renal Transplant, Renal Transplant)
- Diagnosis
  - Chest CT (see Chest Computed Tomography, Chest Computed Tomography)
    - Alveolar Infiltrates (see Pneumonia, Pneumonia): may mimic acute invasive aspergillosis
    - Intracavitary Mycetoma (see Pulmonary Mycetoma, Pulmonary Mycetoma): may mimic an Aspergillus mycetoma (see Chronic Pulmonary Aspergillosis, Chronic Pulmonary Aspergillosis)
    - Upper Lobe Cavitary Infiltrates (see Cystic-Cavitary Lung Lesions, Cystic-Cavitary Lung Lesions): may mimic chronic necrotizing aspergillosis
  - Sputum Culture (see Sputum Culture, Sputum Culture): may demonstrate fungal elements on smear
  - Bronchoscopy (see Bronchoscopy, Bronchoscopy)
    - Bronchoalveolar Lavage (BAL): positive culture may represent only colonization
    - Transbronchial Biopsy (TBB): histopathologically identical to Aspergillus (culture is mandatory to differentiate Scedosporium from Aspergillus)
- Clinical
  - May Present as Slowly or Rapidly Progressive Infection
  - Cough with Sputum Production (see Cough, Cough)
  - Fever (see Fever, Fever)
  - Pleuritic Chest Pain (see Chest Pain, Chest Pain)
  - Tachypnea (see Tachypnea, Tachypnea)

Rheumatologic Manifestations

Osteomyelitis (see Osteomyelitis, Osteomyelitis)
- Epidemiology
  - Occurs in the Setting of Disseminated Infection or Trauma
Soft Tissue Infection
- Epidemiology
  - Occurs in the Setting of Disseminated Infection or Trauma
- Clinical
  - Extremities are the Most Commonly Involved Sites (Although Spine and Skull May Be Involved in Some Cases)

Vascular Manifestations

Mycotic Aneurysm (see Mycotic Aneurysm, Mycotic Aneurysm)
- Epidemiology
  - Occurs in Immunocompromised Hosts
  - Case Has Been Reported in Renal Transplant Patient

Disseminated Scedosporiosis

Epidemiology
- Disseminated Scedosporiosis is Defined as Infection of ≥2 Noncontiguous Body Sites and/or Fungemia
- Occurs Predominantly in Immunocompromised Patients
Clinical
- Central Nervous System Involvement
- Fever (see Fever, Fever)
- Multiorgan Failure
- Sepsis (see Sepsis, Sepsis)
Prognosis
- High Mortality Rate

Treatment

Scedosporium Apiospermum

Azole Antifungals (see Azole Antifungals, Azole Antifungals)

Voriconazole (Vfend) (see Voriconazole, Voriconazole): highest efficacy antifungal (Antimicrob Agents Chemother, 2008) [MEDLINE]
Isavuconazole (Cresemba) (see Isavuconazole, Isavuconazole): may be considered as an alternative

Amphotericin-B (see Amphotericin, Amphotericin)

Response Rates are Considered Poor (J Antimicrob Chemother, 2004) [MEDLINE] (Clin Infect Dis, 2005) [MEDLINE]

Scedosporium Aurantiacum

Azole Antifungals (see Azole Antifungals, Azole Antifungals)

Voriconazole (Vfend) (see Voriconazole, Voriconazole): has a low MIC for this species and may be effective
Posaconazole (Noxafil, Posanol) (see Posaconazole, Posaconazole): has a low MIC for this species and may be effective

References

General

The epidemiology of pseudallescheriasis complicating transplantation: nosocomial and community-acquired infection. Mycoses. 1990;33(6):297 [MEDLINE]
Successful treatment of pneumonia due to Scedosporium apiospermum with itraconazole: case report. Clin Infect Dis. 1993;16(5):731 [MEDLINE]
Successful treatment of simultaneous pulmonary Pseudallescheria boydii and Aspergillus terreus infection with oral itraconazole. Clin Infect Dis. 1993;16(6):803 [MEDLINE]
The new fungal opportunists are coming. Clin Infect Dis. 1996;22 Suppl 2:S112 [MEDLINE]
Scedosporium apiospermum pneumonia after autologous bone marrow transplantation. Eur J Clin Microbiol Infect Dis. 1996;15(7):600 [MEDLINE]
Use of voriconazole in treatment of Scedosporium apiospermum infection: case report. J Clin Microbiol. 1998;36(5):1436 [MEDLINE]
Invasive pulmonary infection due to Scedosporium apiospermum in two children with chronic granulomatous disease. Clin Infect Dis. 1998;27(6):1437 [MEDLINE]
Successful outcome of Scedosporium apiospermum disseminated infection treated with voriconazole in a patient receiving corticosteroid therapy. Clin Infect Dis. 2000;31(6):1499 [MEDLINE]
Pulmonary scedosporium infection following lung transplantation. Transpl Infect Dis. 2001;3(4):189 [MEDLINE]
Uncommon opportunistic fungi: new nosocomial threats. Clin Microbiol Infect. 2001;7 Suppl 2:8 [MEDLINE]
Epidemiology and outcome of mould infections in hematopoietic stem cell transplant recipients. Clin Infect Dis. 2002;34(7):909 [MEDLINE]
Scedosporium apiospermum fungemia in a lung transplant recipient. Chest. 2002;121(5):1714 [MEDLINE]
Pseudallescheria boydii (Anamorph Scedosporium apiospermum). Infection in solid organ transplant recipients in a tertiary medical center and review of the literature. Medicine (Baltimore). 2002;81(5):333 [MEDLINE]
Scedosporium apiospermum pneumonia and sternal wound infection in a heart transplant recipient. Transplantation. 2002;74(11):1645 [MEDLINE]
Fatal pulmonary scedosporiosis. Mycoses. 2003;46(9-10):418 [MEDLINE]
Successful treatment of Scedosporium pneumonia with voriconazole during AML therapy and bone marrow transplantation. Med Pediatr Oncol. 2003;41(5):494 [MEDLINE]
Pseudoallescheria boydii pneumonia and empyema: a rare complication of heart transplantation cured with voriconazole. J Heart Lung Transplant. 2004;23(5):647 [MEDLINE]
Disseminated Scedosporium apiospermum infection in a previously healthy woman with HELLP syndrome. Mycoses. 2004;47(9-10):442 [MEDLINE]
Scedosporium/Pseudallescheria infections. Semin Respir Crit Care Med. 2004;25(2):171 [MEDLINE]
Infections due to Scedosporium apiospermum and Scedosporium prolificans in transplant recipients: clinical characteristics and impact of antifungal agent therapy on outcome. Clin Infect Dis. 2005;40(1):89 [MEDLINE]
Scedosporium infection in a tertiary care cancer center: a review of 25 cases from 1989-2006. Clin Infect Dis. 2006 Dec;43(12):1580-4 [MEDLINE]
Clinical associations and prevalence of Scedosporium spp. in Australian cystic fibrosis patients: identification of novel risk factors? Med Mycol. 2010;48 Suppl 1:S37 [MEDLINE]
Population-based survey of filamentous fungi and antifungal resistance in Spain (FILPOP Study). Antimicrob Agents Chemother. 2013 Jul;57(7):3380-7 [MEDLINE]
Distribution of the different species of the Pseudallescheria boydii/Scedosporium apiospermum complex in French patients with cystic fibrosis. Med Mycol. 2013;51(6):603 [MEDLINE]
Epidemiology, clinical manifestations, and outcomes of Scedosporium infections among solid organ transplant recipients. Transpl Infect Dis. 2014;16(4):578 [MEDLINE]
Scedosporium apiosermum infection of the “Native” valve: Fungal endocarditis in an orthotopic heart transplant recipient. Med Mycol Case Rep. 2015;9:34 [MEDLINE]
Prospective multicenter German study on pulmonary colonization with Scedosporium /Lomentospora species in cystic fibrosis: Epidemiology and new association factors. PLoS One. 2017;12(2):e0171485 [MEDLINE]
Clinical outcome of cystic fibrosis patients colonized by Scedosporium species following lung transplantation: A single-center 15-year experience. Transpl Infect Dis. 2017;19(5) [MEDLINE]

Treatment

A novel murine model of cerebral scedosporiosis: lack of efficacy of amphotericin B. J Antimicrob Chemother. 2004;54(6):1092 [MEDLINE]
Treatment of non-Aspergillus moulds in immunocompromised patients, with amphotericin B lipid complex. Clin Infect Dis. 2005;40 Suppl 6:S401 [MEDLINE]
Treatment of scedosporiosis with voriconazole: clinical experience with 107 patients. Antimicrob Agents Chemother. 2008;52(5):1743 [MEDLINE]