6
ῌ῏ ῑ῍ 膷膰臯膪膁腌膯臸腢膝腌腖腛 Exophiala dermatitidis 腢腪腭腔腖1 腻膂腥腷臬腂膿臗臫腂腾膊腂臠臕臀 臇膯腸臋腊臍臡膮腝 19 3 29 膓腁膦膮腝 20 1 9 膓腁臅腌臌53 臤腁 腈腜腁 膷膰臯膪膁腌腣膵膚腑腌腬腁 膛腔臑膩膄腱臻腟腖腝膒腀 臁X 腁臁CT 腢腏腍腝膔膝膚膼腣膓膕腱腨腁 膚腖腑膺腰腮腛腀 膯臸腣膷膰臯膚膶腧 膖腣腷膉腸腼腽腨腔膤膷腶腛腣臜膳膿腖臄腱腨腛腀 臥臄膜臁臍臡腢腏腍腝腤腁 臐臑腂膷 膰臯膚膶腧腑膜臁腣臊膠腁 膶腢 35膜臁腞腤臞膳膿腸膉腾腆腱臈腖腛腛腨腁 臞 black yeast 腟臚腎腫腮腛腀 腖腐腖腁 27膜臁腞腤臰腣腸膉腾腆腱臈腖腛腛腨腁 腔腖臄腞腌腭 Exophiala dermatitidis 腟膫腖腛腀 miconazole (MCZ) flucytosine (5- FC)itraconazole (ITCZ) 腱膞腎膞腖腁 臒臧腁 臄腣臍腨腫腮腡腍腀 E. dermatitidis 腣臐膑臄腟腖腝腤腧腮腞腌腬腁 臄膌膆腕腮腛腔腟腢腪腬膉腢腡至腑臛腰腮腛腩腣 腟臮腰腮腭腀 膎臈腘膲膞膺immunocomprised patient 膞腖腁 臂腁 臢臂腱膳腨腛膞腩膾腮腕腮腭腛腨腁 臟臓腁 臄臍臡腢腠膅腗腭膣臀腑腌腭腟臮腰腮腭腀 Key words: Exophiala dermatitidis, dematiaceous fungi, pulmonary chromomycosis Exophiala dermatitidis 腂膠膋腏腁 膙腮腛 腡腠臵膨腐腫膭臆腕腮腝腏腬腁 膞臶膴腁 臂腰腏腪腥膛腚膰腣腐腫腩膭臆腕腮腭 1), 2) 腀腕 腫腢腁 膠膨腶膉膆膄腸腆腹腺腁 膙臒腚腣膐腳膥膰腱臺膹腗腭臹臄腂膡膥腟臚腎腫腮腁 臅 膗膻腹腟腡腜腝腍腭 3) 臟膦膢腅腤腁 膷膰臯膪膁腌腗腼腕腮腛膯臸腪腬腁 膞膪腖腝臄腱膭臆腖腛腌臌腱臉臏腖腛腣腞臝腗 腭腀 I. 53 臤腁 腈腜腃膛腔臑腁臁膩膄膵膚腃 膷膰臯膪膁腌 1999 10 臌腈腀 腴臍膸腗腦腒腩腣腡腖腀 腃 膻膗腡腖腁 膸腓膥臍1999 10 腾腅腢膛腔臑膩膄腣腛 腨臅膎腱腁腗腖腁 膷膰臯膪膁腌腗腼腕腮腛腀 腚腣臓腁 tosufloxacin (TFLX) 300 mg/dayclarithromycin (CAM) 400 mg/day 腢腪腭至腣臊膠腁 膐臲腁 腣膧腨腫腮腛腑腁 1999 11 腾腅腁臁腨腁 臲37腉腣膢膖臒腖腛腛腨腁 膼臇膯腸膒腢膣腟腡腜腛腀膩腢腝膾臦腇膅腸腻膈膀膊腃 膘自腳膊膂膉腵腻腆膈腄 膇腙膁腲腆膃腈 腟 erythro- mycin (EM) 600 mg/day 膐膫腖腛腟腔腯腁 2 膲臓腁 膩膄腤膧腖腁 moist rales 腇臶膇膜腈 膀膹腢臑腮腩腓腡腬膧臇臖腱致腖 腛腀 腚腣臓腤腁 膞腗腭腔腟腡腓臉膡膱臨腟腖腛腀 2000 7 臌腁 臐腄臑腱臊膢膖腏腪腥膔腾膚膼膓膕腱腨腁 膩腢腝 EM cefpodoxim (CPDX) 臙臄臦腣至腑臛腰腮腛腑腁 膝膖腤膮膥膋腱臆 腖腛腀 2002 12 臌腁 臋(13)-b-9-腷膈腴膊膟腺臲膲膭腡膵腆膽臘臃腈 4) 40.0 pg/ml 腞腐 11 pg/ml 膍膝腈 腟腎腋腨腫腮腛腀 2003 1 臌臣臼腕腮腛臐臑膥臅膶腗腣腷膉腸腼腽腨腔腢腏 腍腝腰腘腐腢臜膳膿腖臄腱腨腛腛腨腁 膚腖腑膺 腰腮腛腀 膩itraconazole (ITCZ) 300 mg/day EM 400 mg/day 膐膫腢腝臉膡膱臨腕腮腝腍腛腑腁 膧 腙腘腁 臁X 腢臎腫腮腝腍腛膔膝膚膼腣膓 臎臄腤(8300011) 臇膯臭膌67 臇膯腸臋腊臍臡腻膂腥腷TEL & FAX: 0942317760 E-mail: tanamachichiyoko@kurume- u.ac.jp 膓膷臋腊膢腟膬膬臩臱 Vol. 18 No. 1 2008. 膓膷臋腊膢腟膬膬膤 2008 25 25

Exophiala dermatitidis 1 - jscm. · PDF fileand Related Species by Mitochondrial Cyto-chrome b Gene Analysis. J . Clin. Microbiol. 39 4462 4467. 2) Nisimura, K., M. Miyaji. 1982. Studies

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������������ Exophiala dermatitidis ����� ������ 1

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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)/

bxyz" ������*ghY:��( Bi�.��,UV��,{|� Hj}d�/

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�~��&��������) ���

h�����q�6��Ib&�k�b�,��� ��Fzdef�Mzq����'�(�) QRSH�~���q��m��CNq'�� h���������O�Mzq����'�(��� �6���Fz������ (Fig. 3))

II. ������%$������������dPOq����z

��������� Fzq�B�?(�) QRSH�~������q� ��z&&����Fz (1�)

���������  � 20����������������Fz���������) ��Fz�¡PO� ��Fz�¢j£¤ YBC ¥��¦§¨�©£ª ��PO�¢�«(��� 303 24*¬def 48*¬����­¢s®� P����¢¯°�

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.

±²³´µ9¶±²³´µ9¶

�� o·¸¹º»¼ Vol. 18 No. 1 2008.26

26

���� ��� 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

�vwxyz{|} Vol. 18 No. 1 2008. 27

27

��������������� ���������������������������������� (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���

III. ����2�3�4rs�'tu% v5�w6�>I�tx

+�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

ghij,Skghij,Sk

� 4r.�lº»¼ Vol. 18 No. 1 2008.28

28

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�� ��� ����� ������������������� ������� ����������� ����� �!"����##����$%�&�'�%���(���) *����+,���� ��-. empiric therapy� /�0���������1���� ������� !2��2�#3�����) "���� E. der-

matitidis 45#�$%&6�'��7�()*0� ��) 45#�$%&6�+�,-89��� � :;.�/0��<=�>�?@�A �1,-��� 103cfu/ml23�840��'!"�� BC�D��0� ��) "����&�45#�$%&6�+�,-89�� -EF�:;/0��G56��� 103 cfu/ml237H�8I%� MJJ

�)9� P2�:K0�$'�F%2 "��7�()*0� ��) #$ �����;<�L������M= NO�>�P<2?@ �� (Fig.

1-b)��F% !"��QR A��B-�$)E. dermatitidis� C�DSE���F�� 1�G

���) HITUVWXYZ[ HIJ� K\LDCM����� N%� ������#��A���� >�?@�O"��� 7 ��) E.

dermatitidis�L������ P/�#�� ]^Q_RS�8T$��`"U��Va���) bc��MEDLINE�8T de$� E. dermatitidis

�L����'�L�840� ���� 3�11)f13)

� gWXh� Y$DZi�h[�7� �$)"���� 45#j\��kl]��� k^�

45#j\_����`a$�F ���������mn 45#j\_�be$F��oc�p� �d+������� Zeqf�rghO�L�c�D���)i �jk4�ls0� *�mn ����a CM_ m!��n�to0�$�����F�pq0�$) u� !��Lo�rvwx:;.st�@��A ��uv��y[z{|{[��}-� �$) F Cw+$ 89�� G56���$i �x8I��Va0�$) +�,-89�� ~�UY�y,z{�7Huv |��E�E}�G567H ~$$I G56����G������L��� de$����g��e$�� G56�����]�Va$) 27���� ,-�� ��$mn G56��F%��

�M�$$I �9 de$��` SE�tD����� E. dermatitidis���Va$)���)*��Lo������7Ht� MR��G��( �.����,-���Le �G56���$I ���� ! ��oR���,-��������e$)

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� ����

���������g��e$) ���p� �MCZ;<� ���e$)�� ���)�QR%��$I ITCZ� 5-FC�L� 2���� ¡� ¢� ����  B¡A£¢ +� ¤ �A�����)¥£ ��¤¦¥�hO ¦oXh�§¡�¦� "���¤%��Lo� ¨©�ª«�§PC�D�QR%� �$���L�����2Va0� ��) ��89�!��� �)*¬�h���,-�Ox ����� #$����t�^�89��������F%89¨­��e �©ª0��.�89��p���� 89�® � ���-$� B¡�£¢�+,������) #$ «¬QF%2h¯3��%)*0�������$I ­��F!"����F�°����]��±²�XW®¯°YZ±²�Le vI �g���) "������� #����³���e$$IVa$)

� � �� �����L´MICq��®µ¶¥�$3�#$³´µ^C·��89_�¶·¸¹ ³´µ^µ^]�¸^_¹­�º_ºNi¹ ³´µ^]^_Cw^¹­�»» ¼¹�¡¼�$#�)

� �

1) Wang, Li., K. Yokoyama, M. Miyaji, et al. 2001.Identification, Classification, and Phylogeny ofthe Pathogenic Species Exophiala jeanselmei

Exophiala dermatitidis����Exophiala dermatitidis����

O"���^RS Vol. 18 No. 1 2008. 29

29

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.

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ence Guidelines for CLSI Broth MicrodilutionSusceptibility Method (M38-A Document) forAmphotericin B, Itraconazole, Pasaconazole,and Voriconazole. J. Clin. Microbiol. 43: 5243�5246.

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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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