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We report a case of cutaneous infection caused by Phialemonium curvatum GAMS et COOKE, 1983, after bone marrow transplantation. The genus Phialemonium was created by GAMS & MCGINNIS in 1983 including three new species: Ph. obovatum, Ph. curvatum and Ph. dimorphosporum, and represents an intermediate genus between Acremonium and Phialophora. Nowadays, the genus Phialemonium is considered to be a pheoid fungus which may cause the eventual lesions observed in pheo- and hyalohyphomycosis. Species of this genus have been described as opportunistic agents in humans and animals, mainly as a result of immunosuppression. In the present case, the patient had multiple myeloma and received an allogenic bone marrow transplant from his HLA-compatible brother. Two months after transplantation, he developed purplish and painful nodular lesions on the right ankle. Some of these lesions drained spontaneously and apparently hyaline mycelial filaments were observed, whose culture was initially identified as Acremonium sp. Subsequent studies showed that the fungus was Phialemonium curvatum. The infection was treated with amphotericin B, followed by ketoconazole. The patient was submitted to surgical debridement followed by two skin grafts to repair the bloody area. The duration of the treatment was 4 months and secondary prophylaxis with ketoconazole alone was maintained for one additional month. No recurrence was observed after discontinuation of treatment. The authors comment on the pathogenicity of the genus Phialemonium.

A forty-year-old man underwent an allogeneic BMT from his HLA identical sister. GvHD prophylaxis was done with cyclosporine (CyA), methotrexate and prednisone (PDN). On day +90 extensive GvHD was noted and higher doses of immunosuppressive drugs alternating CyA with PDN were initiated. Patient's follow-up was complicated by intermittent episodes of leukopenia and monthly episodes of sinusitis or pneumonia. One year after BMT, the patient developed hoarseness and nasal voice. No etiologic agent could be identified on a biopsy sample of the vocal chord. Upon tapering the doses of immunosuppressive drugs, the patient had worsening of chronic GvHD and was reintroduced on high doses of cyclosporine alternating with prednisone on day +550. Three months later, GvHD remained out of control and the patient was started on azathioprine. On day +700, hoarseness and nasal voice recurred. Another biopsy of the left vocal chord failed to demonstrate infection. Episodes of sinusitis became more frequent and azathioprine was withheld 3 months after it was started. One month later, the patient had bloody nasal discharge and surgical drainage of maxillary sinuses was performed. Histopathology showed hyphae and cultures grew Scedosporium apiospermum. ltraconazole 800 mg/day was initiated. The patient developed progressive respiratory failure and died 15 days later.Paciente portador de leucemia mielóide crônica, com irmã HLA-compatível foi submetido a transplante alogênico de medula óssea. No dia +90 pós-TMO foi diagnosticado doença do enxerto contra o hospedeiro (DECH) extensa e iniciado protocolo alternado de imunossupressão com altas doses de ciclosporina A e prednisona. O seguimento ambulatorial foi complicado, com granulocitopenia intermitente e quadros frequentes de sinusite e pneumonia. Um ano após o transplante, o paciente apresentou rouquidão e voz anasalada. Foi realizada uma biópsia de corda vocal mas nenhum agente infeccioso pode ser identificado. Na diminuição das doses das drogas imunossupressoras, houve piora da DECH crônica e foi reiniciado esquema de doses altas no dia +550. Três meses após, permanecendo o quadro de DECH fora do controle, foi tentado imunossupressão com azatioprina sem sucesso. Novo episódio de rouquidão foi observado no dia +700, mas nenhum agente pode ser identificado em nova biópsia de corda vocal. Após um mês, o paciente apresentou secreção nasal sanguinolenta e foi realizada uma raspagem cirúrgica dos seios maxilares. Scedosporium apiospermum foi identificado nas culturas iniciando-se itraconazol na dose de 800 mg/dia. O paciente desenvolveu falência respiratória progressiva e foi a óbito em 15 dias.