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�" 53 # !� ������ $%&'( )�"*#+�$,-%*�.&�/ +�X'0� +� CT �12.34�( 56,)7 ����&89:/ �� ����*+,; <=>?@-�.��/0 A12��,)7/ B�34���12." 5"�����*+,;34 CD �E6F� 35G34H"��A12>=IJ,K��7 ��A1 black yeast *LMN:/ �O� 27G34H"P7 >=IJ,K��7 8K�����H'� Exophiala dermatitidis *Q9�/ miconazole (MCZ) � flucytosine (5-
FC) itraconazole (ITCZ) ,RMR:� ST � �;")7N:U2/ E. dermatitidis "���� VW�*�."X:H'( �<&=9Y:Z*�(>?U�:&[9:\ *]9:�/ ^:@A BC immunocomprised patient "DR� E_ `_,a7��� DR\FGY:�7 bc �����HId�JK&'�*]9:�/
Key words: Exophiala dermatitidis, dematiaceous fungi, pulmonary chromomycosis
� �Exophiala dermatitidis "LeMN OP f:Q R SUghTiONUVY:.1( Rjk WX Q1lYQ� ZON\UVY:�1), 2)/ YN� N[m=no>Jpq N4\] ^r _ `a�b,std�uc��d�V�*LMN: v�ef*Uw.2�3)/
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I. � �� ~ 53 # !�/- %~ )�" +�$/$%k~ ������ �1999� 10 �!/�lk~ m�d��\ U�/n�k~ ��kU� op/
S�k~ 1999� 10 ��q�)�" #+�$ 7v^,�g� ������*ghY:/r c tosufloxacin (TFLX) 300 mg/day clarithromycin
(CAM) 400 mg/day ���: CD �� #+�$ �r")7N:& 1999� 11 ��q +$,)7 �s 37G tu&;S�7 ��������v�*Uw/�w�.�"���>����~�����=��J�� xy��J�! * erythro-
mycin (EM) 600 mg/day `zR:�*Z� 2
{�c #+�$"�r� moist rales �j���!"|}��~ " ?:\��U(�r ¡,¢�/ r c" R:d�Z*U�{£¤¥*�/2000� 7 � 5;" D� tu1l3��(�56,)7 �w�. EM * cefpodoxim (CPDX) ¦�� �:&[9:& "*�u"§¨�©,ª(��/ 2002� 12 � «� (1¬3)-b-9-<��������U��� �®��¯°!4) 40.0 pg/ml ����~ 11 pg/ml ±4! *��&)7N:/ 2003� 1
�²³Y:5" � B*g <=>?@-��12.9´O�A12��,)77 ����&89:/ �wH itraconazole (ITCZ) 300 mg/day *EM 400 mg/day`z�.{£¤¥Y:.2& �rµ´ +� X'0��¶N:.234�( 5
|����~ (·830�0011) ���¸¹� 67�������������� �TEL & FAX: 0942�31�7760E-mail: tanamachi�[email protected]
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���������� � ���� CT������������������� 2003� 7� 14� !�"�#$�%$&'(�)%$*+,- ./ 156 cm� 0 1 50 kg� 0 2
36.83� 456 14/7� �8 72/79:� ;< 116/
70 mmHg� =��>�?@� AB�����C�?(�) �� XDEF�GHI�&JK�L0��M�M��CN OP� (Fig. 1-a)) �� CT�� X
DEF&������ QRST�UV&QRS�WXY�Z(OP� (Fig. 2)) [;�\!+,�Table 1�� �) CRP�]^_`� a;b��cdef (1g3)-b-9-hijkl�]^_`����)��m�n+,- onpqHr� Hst� Huv
wixivy� defmzBH{�|P� QRS}\!�OQRSH�~��&��������) ���
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II. ������%$������������dPOq����z
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Fig. 1. Chest X-ray photo of the patienta) Shadow in the lower right field on admission (red arrow).b) Improved shadow after treatment.
Fig. 2. Chest CT scana) Reticular-granular shadow and exteded bronchi wall are recognized in the right middle lobe.b) Same findings are recognized in the right lower lobe.
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���� ��� API 20C AUX ���� ��� ������������ 30� 24��� 48��� 72������ �!"� �#$%��&'(����)*+,-.(/012�34�56/789:;
<�=2>��?@A����� �BC6DE<F���GD<HIJ�K�� LM�5CA�012�34�5 ��NOP� �Q�A� 27�(RS��6TUVWXYCZ[\]��^ (Slide Culture)5)6TU_`����� VWXY�?@(/� 27�� a 2b����(cd�efA� gh(D<�SiJH�jkUVWXY�lGm$�� 3b��TnJH)*�op
Table 1. Laboratory data on admission
Complete blood countWBC 11.7q103/ml Acid-fast stain Negative
Bas 0.2r PCREo 0.9r M. tuberculosis NegativeNeu 79.3r M. avium complex NegativeLy 13.7r Culture on Ogawa NegativeMo 5.9r Aspergillus antigen Negative
RBC 4.51q106/ml Anti-Aspergillus Ab NegativeHb 13.4 g/dl (ELISA)Ht 42r Cryptococcus antigen Negative
Plt 20.1q104/ml b-9-Glucan 27.3 pg/mlLaboratory data
TP 7.25 g/dLGOT 13 IU/LGPT 7 IU/LLDH 166 IU/LALP 276 IU/LBUN 9.4 mg/dLCr 0.64 mg/dLCRP 2.37 mg/dL
Fig. 3. Many yeasts in bronchial washings ofthe patient (Grocott stain q400)
Fig. 4. Giant colony cultured on 30th day
Exophiala dermatitidisstJuExophiala dermatitidisstJu
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��������������� ���������������������������������� (Fig. 4)�
Slide Culture 30���� �!"#$% &�'()*+)*��� �,'-�./#0�1234� annellide��56�� 1234�$% 7389:��% 12�: ;<�:= �, annelloconi-
dium-��>�?% @'����$<�+A6���'B�5�� �,$% �&�# 1C���,% �D-��>% 1234�����E��>F�EG��>��'�H�#I� (Fig. 5)� ��%37J� K 42J#��LM�#0��� ���%NOPQRS�QR8�� ;Czapek Dox agar% ����= �� ��L$��#0?TUV�WX���Y�#0�� Z[ ? )$% \!"#) (Candida
spp.)#$�]% E. dermatitidis+^_$`��6)���% amphotericin B (AMPH)% 5-fluorocytosine
(5-FC), fluconazole (FLCZ), miconazole (MCZ), mica-
fungin (MCFG)% itraconazole (ITCZ)'a#)��
%��^b&L'c() (MIC)*+d��� MIC
'*+�$ Clinical and Laboratory Standards In-
stitute (CLSI)',e-M27-A�ef��./g0hi-���7)j9)� a#)��%��MIC1Table 2�k��� @'lm% MCFG���>$n�MIC1k���%@6Zo'�p���>$�q�lmk���
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+�yz{|}% ~���7s�8�18P���8� �9#)s10)�&s��+yz6% :��$MCFG150 mg/day';<=>�>�5��� �5�� 2�����d���� CT#$% :�?+@��A03�YB$����#0��� MCFG 300
mg/day��/�% � @ 10�tu���s����$�56�% BCDc��� )�'E+% ���lm�F6��#% oG���>tu�� ;Hv5= �6>���% 2004I 3� 4�% �D�J'K�B'���5% �:�+���� L) E. der-
matitidis'���lm ?% EI 3� 13� ?% M��+�>�N% OP��' �.s�'�#% 9Q¡¢'£d�� ]% �¤¥¦�R##)�Ss�§|6�+I�¨��6�MCZ 400 mg/day�TUBC�6�� 2���'�� XV©#% �� CT#$ªW���0?% ��?��X% «Y% Z[��'s�'ªW��5��5% MCZ 4��BC�% 2004I4� 14��\�+����
2003I 1� ?% ]¬�#)s'^TU�+�>®]¨��6� ICTZ'_`�5�oG�>BC�6��% p$9¢'a.£d���¯+�b�����56�� @'lm% 2004I 4� 14�\��'oGv5$% ��°±'²�� 5-FC 100 mg/kg/
day% ITCZ 200 mg/day� � 2pc��>�5³d�>��� \��% #)�# E. dermatitidis'"´$�56�% 4rµA% ¶eµA$ªW�% ·¬��f$�]tu�q#0��
Fig. 5. Slide culture on 30th day (Lactophenolstain ¸400)
Table 2. Susceptibility of antifungal drugs(27J, 72 hours cultured)
AMPH-B 0.25 mg/ml5-FC 4 mg/mlFLCZ 8 mg/mlITCZ 0.25 mg/mlMCZ 0.125 mg/mlMCFG ¹16 mg/ml
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E. dermatitidis� ���,-�� � ,-�3 35�� 27��MR����L� t��G56����M����tD�����) 10���`SE�� ����$I��������A �������L�84�����14)) ����Fx�G����� t��c�D� ��3�D ��������g�@� �Q�����2.`?3� �����t�����g�� d� ��) ������� �����3 ,-Ox�@��� ������� ����t� LAw� �A��������)"��������d-�$���L� ����
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1) Wang, Li., K. Yokoyama, M. Miyaji, et al. 2001.Identification, Classification, and Phylogeny ofthe Pathogenic Species Exophiala jeanselmei
Exophiala dermatitidis����Exophiala dermatitidis����
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and Related Species by Mitochondrial Cyto-chrome b Gene Analysis. J . Clin. Microbiol. 39�4462�4467.
2) Nisimura, K., M. Miyaji. 1982. Studies on asaprophyte of Exophiala dermatitidis isolatedfrom fumidifler. Mycopathologia 3(77): 173�181.
3) Revankar, S. G. 2007. Dematiaceous fungi. My-coses 50(2): 91�101.
4) ����� 2002. �� (1,3)-b-9-�� �������� �� 61: 28�37.
5) ����� 2002.����� !"�#$%&�p. 110�115, '()*+,-./+0�
6) 12345 6789� 1994.:;<���=>���?@A5 BCDE'()*5 p. 189�190.
7) National Committee for Clinical LaboratoryStandards (NCCLS). 1997. Reference methodfor broth dilution antifungal susceptibilitytesting of yeastsF Approved Standard. NCCLSdocument M27-A. NCCLS, Wayne, Pa.
8) G7HI5 �JKL5 �M N5 O� 2002.PQ�RS�TU:;Vmicafungin� in vitroU:;WX� �YDEZ[E)\] DEC� 8�18.
9) Espinel-Ingro#, A., A. Fothergill, M. Ghan-noum, et al. 2005. Quality Control and Refer-
ence Guidelines for CLSI Broth MicrodilutionSusceptibility Method (M38-A Document) forAmphotericin B, Itraconazole, Pasaconazole,and Voriconazole. J. Clin. Microbiol. 43: 5243�5246.
10) ^M_`� 2002.ab�c:;<�de� �� 61:1�7.
11) Horre, R., K. P. Schaal, R. Sielmeier, et al. 2004.Isolation of fungi, especially Exophiala dermati-tidis, in patients su#ering from cystic fibrosis.A prospective study. Respiration 71(4)� 360�366.
12) Diemert, D., D. Kunimoto, C. Sand, et al. 2001.Sputum isolation of Wangiella dermatitidis inpatients with cystic fibrosis. Scand . Infect. Dis.33(10)� 777�779.
13) Blaschke-Hellmessen, R., I. Lauterbach, K. D.Paul, et al. 1994. Detection of Exophiala derma-titidis (Kano) De Hoog 1977 in septicemia of achild with acute lymphatic leukemia and inpatients with cystic fibrosis. Mycoses 37: 89�96.
14) fg�h� 2002. ijk���lmnopX� �� 61: 19�27.
A Case of Pulmonary Chromomycosis Caused by Exophiala dermatitidis
Chiyoko Tanamachi, Kouji Hashimoto, Kazunori Nakata,
Kimitaka Sagawa
Department of Laboratory Medicine, Kurume University Hospital
We report a rare case of pulmonary mycosis involving E. dermatitidis. The subject was a 53-year-oldwoman with a history of bronchiectasis whose primary complaints at the time of hospitalization wereyellowish phlegm and anterior chest pain. Chest X-rays and chest CT images revealed a shadow in thelower right lung field, and pulmonary mycosis was suspected. Grocott staining of samples from the pa-tient’s bronchial lavage fluid showed many yeast-like fungi. When coughed up sputum and bronchiallavage fluid were cultured at 35q, colonies formed which appeared to be black yeast. However, whencultured at 27q filamentous colonies formed, so we confirmed a diagnosis of the dimorphic black yeastExophiala dermatitidis. After initial treatment with miconazole, combined treatment with itrazonazole andflucytosine proved e#ective.
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