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Lacaziosis Presentation prepared by:

Omair, Mohney, Bischoff

Emedicine.medscape.com

mycology.adelaide.edu

mycology.adelaide.edu.

Lacaziosis Terms   1938-Originally called Lobo disease

  1958-The name lobomycosis was applied

  2005-The name lacaziosis was made the official term for condition

  Jorge Lobo first described this as keloidal blastomycosis in a patient from the Amazon Valley of Brazil

dermatlas.med.jhmi.edu

Lacaziosis Taxonomy   Kingdom: Fungi

  Phylum: Zygomycota

  Subphylum: Zygomycotina

  Order: Entomophthorales

  Family: Uncertain

  Genus: Lacazia

  Species:Loboa loboi, Lacazia loboi(most recent name),

Lacaziosis Distribution   Self-limited, chronic infection of the skin endemic

in rural regions of South America and Central America

  Since the original report, has also been reported by North Americans traveling to endemic areas   Only 1 case of lobomycosis has been reported in the

United States

  Also reported in 2 species of Atlantic dolphins, and 1 marine park dolphin trainer

scielo.org.ve oceanservice.noaa.gov

Lacaziosis Life Cycle   A yeast-like fungus, with aquatic environment

needed for life cycle

  Slow growth, only with long incubation

  Unfortunately, cannot be grown in culture, therefore, not much is known of the environment needed for growth

microbeworld.org In pus from a lesion

saber.ula.ve Stain of loboa loboi

How people are affected:   Traumatic implantation most often the case

  Arthropod sting

  Snake bite

  Sting-ray sting

  Wound acquired while cutting vegetation

jcm.asm.org First human case of lobomycosis

nejm.org ucsantacruz.ucnrs.org

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Who is affected:   Wide age range between 12 and 70 years

  No ethnic predominance and all races seem to be equally susceptible

  Occupation of those affected tend to be persons who carry out agricultural activities, as well those dedicated to fishing, hunting and mining

  90% of cases are men

superstock.com telegraph.co.uk

Lacaziosis Symptoms   Cutaneous & subcutaneous

  Begin as small, hard nodules

  Keloids, nodular lesions, crusty plaques, and tumors

  Developing lesions are smooth, painless, and well defined, move around a bit, because on top of tissue

  Older lesions can become ulcerative

  Lesions are usually found on the arms, legs, face or ears

  May be transferred to other areas of of the skin by further trauma or autoinoculation

Jcm.asm.org Lobomycosis of leg

Symptoms (cont.)   Lesions are composed of

  granulomatous inflammatory tissue containing numerous globose or subglobose or

  lemon-shaped, yeast-like fungal cells singly or in simple and branched chains.

elsevierimages.com

studydroid.com

emedicine.medscape.com

Diagnosis of Lacoziosis   A tissue sample is obtained by curettage,or surgical

biopsy

  Then this tissue can either be macerated and mounted in 10% KOH and Parker ink or calcofluor white mounts or

  Tissue sections can be stained using Grocott's methenamine silver or Gram stains

  If present, dark, spheres of yeast-like organisms will show, known as Loboa loboi, often in chains

  Presently no serological tests available mycology.adelaide.edu.au

Treatment   Wide surgical excision of affected area

  Relapse often occurs, and so the excision must be wide

  Often, new lesions may occur from surgery

Prevention   Relapse is extremely common

  Upon removal of lesions, Clofazimine 100-200 mg/day can be used to prevent, though its results vary

  Appears antifungals are not effective

  Though the course of infection is slow and chronic the prognosis is poor

drugster.info rxlist.com

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Case Report 1   Part 1:   62 year old male   Injured his ear when he was ~52 with a

fishhook   A hard nodule developed, followed by

satellite lesions.

  Initially diagnosed as lepromatous leprosy.

  Microscopic findings confirmed lobomycosis

  The patient refused otoplasty and was treated with itraconazole; some nodules partially regressed.

http://www.cdc.gov/eid/content/15/8/pdfs/1301.pdf

Case Report 1   Part 2:

  Bottlenose dolphin: male.

  Symptoms: missing teeth, several pink, whit and gray lesions

Although the human and dolphin cases weren’t probably related, they suggest the role of the marine environment as a likely natural habitat

for L. loboi and as a reservoir for infection.

Case Report 2   A 42-year-old white male patient, a resident of

Georgia, presented to a general surgeon.

  The patient requested removal of a skin lesion on his right chest wall for cosmetic reasons.

  Seven years earlier, the lesion had started as a small pustule with surrounding erythema.

  At that time, the patient pierced the pustule with a needle and then expressed a tiny amount of bloody fluid.

  Afterwards, the lesion developed into a small nodule that gradually increased in size w/ some mild itching only.

Case study 2 Cont.:-   Two and one-half years prior to the appearance of the

pustule, the patient had traveled to Venezuela.

  He walked under the Angel falls in Canaima at least 3 times-3000ft high water pressure-30 min each exposure. Swam in the bottom of the falls.

  Wore diving suit but was still soaked in water.

  3.5- by 2-cm reddish purple nodule with a smooth surface and distinct margins located on the right chest wall in the midaxillary line at the level of the eighth rib. It had the appearance of a keloid. After an uncomplicated excision, the excised tissue was sent for pathologic evaluation.

Case study 2 Cont.:-   The excised tissue, fixed in formalin, was a skin

ellipse which measured 4.9 by 2.6 by 0.6 cm, with the lesion measuring 3.5 by 2.1 cm.

  No fresh tissue was saved for bacterial or fungal cultures.

Globose to subglobose cells in a chain with distinctive tubular connectors and a cell showing multiple buds. Gomori's methenamine silver stain was used. Magnification, ×770.

Case Study 2 Cont.:-   The globose and subglobose budding cells of

L. loboi resemble budding cells of P. brasiliensis in tissue.

  However, the central mother cells of P. brasiliensis become large and thick-walled compared to the daughter cells, which remain smaller.

  In contrast, yeast cells of L. loboi remain consistent in diameter, giving rise to branching chains of blastoconidia.

  The cell wall of L. loboi contains constitutive melanin unlike P. brasiliensis, which can be detected by the use of the Fontana-Masson histologic stain.

  L. loboi has never been cultured in vitro.

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References   www.drfungus.org

  Al-Daraji WI. Cutaneous lobomycosis: a delayed diagnosis. Am J Dermatopathol. Dec 2008;30(6):575-7.

  Bermudez, Luis. "Lobomycosis in Man and Lobomycosis-like Disease in Bottlenose Dolphin, Venezuela." Emerging Infectious Diseases 15.8 (2009): 1301-303. Print.

  Talhari C, Chrusciak-Talhari A, de Souza JV, Araujo JR, Talhari S. Exfoliative cytology as a rapid diagnostic tool for lobomycosis. Mycoses. Mar 2009;52(2):187-9.

Robert A. Burns, J. Stephen Roy, Cavan Woods, Arvind A. Padhye,and David W. Warnock. Report of the First Human Case of Lobomycosis in the United States. Journal of Clinical Microbiology. March 2000; 38(3):1283-85.