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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~  References
 ~  Article Figures

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  Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 31  |  Issue : 3  |  Page : 308-310
 

Alternaria alternata in a case of mass in the lung


1 Department of Microbiology, Osmania Medical College, Hyderabad, Andhra Pradesh, India
2 Department of Pulomonology, Osmania Medical College, Hyderabad, Andhra Pradesh, India

Date of Submission14-Nov-2012
Date of Acceptance26-May-2013
Date of Web Publication25-Jul-2013

Correspondence Address:
R P Shashikala
Department of Microbiology, Osmania Medical College, Hyderabad, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.115667

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 ~ Abstract 

A 50-year-old woman, an agriculture worker with diabetes and asthma presented to us with complaints of fever with chills, cough with scanty, mucopurulent sputum and dull aching chest pain in right mammary area radiating to axilla. Chest X-ray and computed tomography scan revealed mass in the right lung. Ultrasound guided fine-needle aspiration cytology was done and the greenish fluid on direct wet mount and inoculation on Sabouraud's dextrose agar isolated Alternaria species. Serum specimen was evaluated for immunoglobulin E specific titres for Alternaria species which was high. Patient was treated with fluconazole for 6 weeks after which the symptoms disappeared and chest X-ray was normal.


Keywords: Alternaria, fungal infection, immuno-compromised, lung abscess


How to cite this article:
Shashikala R P, Saikumar A, Ramesh K, Aparana V. Alternaria alternata in a case of mass in the lung. Indian J Med Microbiol 2013;31:308-10

How to cite this URL:
Shashikala R P, Saikumar A, Ramesh K, Aparana V. Alternaria alternata in a case of mass in the lung. Indian J Med Microbiol [serial online] 2013 [cited 2019 Sep 23];31:308-10. Available from: http://www.ijmm.org/text.asp?2013/31/3/308/115667



 ~ Introduction Top


Fungal infections have become a major source of morbidity and mortality in immuno-compromised patients. As our abilities to treat and cure haematologic diseases and transplant organs increase, we continue to encounter new and rare pathology. Alternaria alternata is an uncommon cause of invasive fungal infection.

Alternaria is more commonly implicated in pulmonary nodules and chronic sinusitis. In the immunocompromised patient, Alternaria is recognised as a source of cutaneous, sinus, nail, palatal, and ocular infections, particularly A. alternata.

There are 299 species in the genus. [1],[2] They are ubiquitous in environment and part of fungal flora almost everywhere. They are normal agents of decay and decomposition. The spores are airborne and found in the soil and water, as well as indoor and objects.

The club shaped spores are single or form long chains. They can grow thick colonies, which are usually green, black, or grey. [1],[2]

Alternaria chartarum, Alternaria dianthicola, Alternaria geophila, Alternaria infectoria, Alternaria stemphyloides, Alternaria teunissima are other species isolated from infections. Different species are distinguished based on characteristics of conidia and chain formation. [3],[4]

To the best of our knowledge, only 210 cases were reported in literature between 1933 and 2007 with 74% being cutaneous. 17 cases of invasive rhinosinusitis with Alternaria were noted since 1977. Only 5 had species identification with 4 of these being A. alternata. 12 of 17 were immunocompromised while 10 of 17 had acute leukemia with neutropenia. Disseminated disease has not been described in Alternaria infection. [1],[2],[3],[4],[5],[6] We report a case of right lung mass infected with Alternaria species in a diabetic patient.


 ~ Case Report Top


A 50-year female agriculture worker with a 10 years history of asthma and 4 years history of diabetes mellitus, presented with 2 months duration of chest pain in right mammary area, cough with purulent sputum and streaky hemoptysis. The chest pain was dull aching type in the right mammary area, radiating to right axilla, aggravated by cough and lying down on same side. Pain was relieved by medication, fever was high grade, with chills and rigors, 2-3 h in afternoon, touching base line in the evening, there was no associated rash. Cough was associated with scanty mucopurulent sputum and streaked with blood.

Patient was treated for asthma with inhaled steroids, oral steroids, antibiotics and hypoglycemic agents. Patient was of thin built and ill-nourished. On inspection, right chest movements were decreased. On palpation the right side chest movements were decreased, dull note in right mammary area. On auscultation coarse, inspiratory crepts and vocal resonance low in right mammary area. Chest X-ray showed non-homogenous opacity in right mid-zone [Figure 1]. Computed tomography (CT) scan showed large area of increased attenuation showing homogenous enhancement with predominant necrosis in right upper and middle lobe [Figure 1]. Bronchoscopy revealed erythematous bronchus of the right middle lobe. Bronchial washings did not yield any bacterial growth. Post-fibreoptic bronchoscopy sputum was negative for acid fast bacilli. Ultrasound guided fine-needle aspiration cytology of right lung lesion yielded greenish pus; 20 ml was aspirated and sent to pathology and microbiology.
Figure 1: Chest X-ray showing non-homogenous opacity in right mid-zone. Computed tomography scan chest showing large areas of increased attenuation with homogenous enhancement and predominant necrosis in right upper and middle lobe

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Diagnosis and treatment

Pathology reported necrotic background suggestive of suppurative lesion. In microbiology, direct microscopy with 10% KOH showed brownish septate hyphae, which were branched [Figure 2]. Specimen was inoculated on blood agar, McConkey agar, plain Sabouraud's dextrose agar (SDA without antibiotics) and SDA with cycloheximide and a cottony growth was seen on 3 rd day on plain SDA. It was greyish on the obverse and brownish on the reverse [Figure 2] Lactophenol cotton blue mount was done with this culture, which showed branched septate hyphae and short conidia with a small beak which were arranged in chains resembling Alternaria alternata with the conidia having both longitudinal and transverse septae [Figure 2]. A. infectoria is also branched but conidia often have long apical secondary conidiophores. Young chains of A. tenuissima have simple and long chains (8 to 15 or more conidia). There was no growth on Blood agar and MacConkey agar.
Figure 2: Plain Sabouraud's dextrose agar shows cottony growth, greyish on the obverse and brownish on the reverse. Lactophenol cotton blue mount shows branched septate hyphae and short conidia arranged in chains with transverse and longitudinal septa

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Patient was treated with fluconazole for 6 weeks but was recalled within 3 weeks for a serum sample to evaluate immunoglobulin E (IgE) specific titres for Alternaria spp. In a local lab report showed 1.5 kU/L for allergen, which is considered high. The test method used was fluorescence enzyme immunoassay. Patient was relieved of symptoms within 4 weeks.


 ~ Discussion Top


Alternaria species have emerged as opportunistic pathogens particularly in patients with immunosupression, such as the bone marrow transplant patients. Cases of onychomycosis, sinusitis, ulcerated cutaneous infections and keratitis as well as visceral infections and osteomyelitis due to Alternaria have been reported. [1],[2],[4] In immunocompetent patients Alternaria colonizes the paranasal sinuses, leading to chronic hypertrophic sinusitis. It is among the causative agents of otitis media in agricultural field workers. Baker's asthma is associated with inhalation of Alternaria conidia present in flour. Farmer's lung has also been reported recently. [5],[6]

Since Alternaria species are cosmopolitan and ubiquitous in nature, they are also common lab contaminants. Thus their isolation in culture requires cautious evaluation. [5]

Verini et al. in a study evaluated frequency of allergies in asthmatic children of age 1-17 years by using skin-specific IgE determination for common allergens showed 13% were sensitized to Alternaria. [6]

In our case the patient is an agricultural worker with predisposing factors of diabetes and asthma. Clinical picture has proved to be rare since Alternaria has never been isolated in a case of lung mass. However direct wet mount showed branched septate hyphae brown in colour and culture has proved beyond doubt that Alternaria is the pathogen. High IgE titres specific for Alternaria reinforced the diagnosis.

Hence we conclude that in any case of chronic sinusitis, eosinophilic pneumonia in an immunocompromised individual, not responding to antibiotics clinicians and microbiologists should be highly aware and make efforts to anticipate Alternaria and process accordingly. Evaluation of IgE specific titres is a useful adjunct in diagnosis.

 
 ~ References Top

1.Kpodzo DS, Calderwood MS, Ruchelsman DE, Abramson JS, Piris A, Winograd JM, et al. Primary subcutaneous Alternaria alternata infection of the hand in an immunocompromised host. Med Mycol 2011;49:543-7.  Back to cited text no. 1
[PUBMED]    
2.Gürcan S, Piºkin S, Kiliç H, Temelli BA, Yalçin O. Cutaneous infection caused by Alternaria alternata in an immunocompetent host. Mikrobiyol Bul 2009;43:163-7.  Back to cited text no. 2
    
3.Anaissie EJ, Bodey GP, Rinaldi MG. Emerging fungal pathogens. Eur J Clin Microbiol Infect Dis 1989;8:323-30.  Back to cited text no. 3
[PUBMED]    
4.Garau J, Diamond RD, Lagrotteria LB, Kabins SA. Alternaria osteomyelitis. Ann Intern Med 1977;86:747-8.  Back to cited text no. 4
[PUBMED]    
5.Pritchard RC, Muir DB. Black fungi: A survey of dematiaceous hyphomycetes from clinical specimens identified over a five year period in a reference laboratory. Pathology 1987;19:281-4.  Back to cited text no. 5
[PUBMED]    
6.Verini M, Rossi N, Verrotti A, Pelaccia G, Nicodemo A, Chiarelli F. Sensitization to environmental antigens in asthmatic children from a central Italian area. Sci Total Environ 2001;270:63-9.  Back to cited text no. 6
[PUBMED]    


    Figures

  [Figure 1], [Figure 2]

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