JOURNAL OF CLINICAL MICROBIOLOGY, JUIY 1982, p. 181-1850095-1137/82/070181-05$02.00/0

Vol. 16, No. 1

Gluteal Abscess Caused by Phialophora hoffmannii andReview of the Role of This Organism in Human Mycoses

MICHAEL G. RINALDI,l* EDNA L. McCOY,2 AND DEAN F. WINN3Department of Microbiology, Montana State University, Bozeman, Montana 59717,1 and MicrobiologySection, Department ofPathology,2 and Department of Surgery,3 Woodland Clinic Medical Group,

Woodland, California 95695

Received 14 September 1981/Accepted 1 April 1982

Infections caused by members of the Phialophora hoffmannii (Beyma) Schol-Schwarz fungal aggregate (a group of related taxa, especially species of uncertaincircumscription) are not reported frequently. This case report concerns thedevelopment of a gluteal abscess after multiple intramuscular injections ofantimicrobial agents. Microbiological examination of the abscess material yieldeda pure growth of the mold P. hoffmannii. Hyphal elements in the purulent exudatewere only demonstrated when the specimen was digested by an N-acetylcysteine-NaOH digestion-decontamination procedure or in stained paraffin blocksections of the exudate. Other cases of disease caused by members of this fungalaggregate and the status of the mycology of this organism are reviewed.

The spectrum of human mycoses has broad-ened dramatically in recent years. Fungi whichwere seldom, if ever, reported as agents ofinfectious diseases are becoming more prevalentin contemporary medicine. This may be a resultof increased awareness of mycotic disease,greater mycological acumen in medicine, andtremendous advances in medical technology (4,7, 16, 19). This report documents an infection bya fungus rarely encountered as a human patho-gen, Phialophora hoffmannii (Beyma) Schol-Schwarz.Members of the genus Phialophora Medlar

are ubiquitous fungi which cause discolorationand soft rot of wood and are found in water, soil,and food. In humans, species of Phialophorahave caused chromoblastomycosis (a mycoticinfection of the cutaneous and subcutaneoustissues characterized by the development ofdematiaceous sclerotic bodies) and phaeohypho-mycosis (an infection of humans and lower ani-mals caused by a number of dematiaceous fungicharacterized by the development of dematia-ceous hyphae in the tissue which are short orelongated, distorted or swollen, regular or irreg-ular in form). Fungi in the P. hoffmannii aggre-gate have caused human disease (14, 18). Themycological status of the causative agents needsfurther study and clarification (14, 18). Thiscommunication describes an abscess caused byP. hoffmannii and discusses the mycologicalaspects of this isolate.

CASE REPORTOn 6 November 1979 a 73-year-old female was seen

for a routine physical examination in her physician's

office. She mentioned briefly her concern about theoccurrence of a lump on her left buttock. The physi-cian's impression was that the patient had either asterile or septic abscess. She was referred to a surgeonfor further evaluation.The surgeon saw the patient on 7 November 1979.

According to the patient, the lump had increased insize and become tender and painful over a period of 4months. Purulent material (110 ml) was aspirated fromthe abscess and sent to the laboratory for routinebacterial culture. Although not requested by the physi-cian, cultures for fungi and acid-fast bacilli were alsoset up by the technologist.A history from the patient revealed that she had

been traveling in Spain in July, 1979, and had devel-oped a respiratory infection diagnosed as pneumonia.After a number of antibacterial drug injections, shenoticed a small lump in the area where the injectionshad been given.The routine culture for bacteria made on 7 Novem-

ber was reported as no growth on 10 November 1979.In the microbiology laboratory of the Woodland ClinicMedical Group, all pertinent anaerobic culture platesare held for 10 days. On 13 November 1979, theanaerobic plate containing a specimen from the patientwas noted to show five colonies of a mold. The platehad been removed from anaerobic conditions every 48h for examination and hence was exposed to aerobicconditions periodically. This accounted for the pres-ence of an aerobic organism initially noted to begrowing under anaerobic conditions. After reexamin-ing the primary cultures, a few mold colonies wereobserved growing on several plates and tubes. Thephysician was notified of a possible mycotic infection.On 13 November 1979, the patient was seen again in

the physician's office, and approximately 60 ml ofpurulent material was aspirated and sent to the labora-tory for bacterial, fungal, and acid-fast bacilli cultures.All of these cultures grew out a filamentous moldwhich resembled the organism isolated from the cul-

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182 RINALDI, MCCOY, AND WINN

FIG. 1. Gluteal abscess: area of healing incision.

ture of 7 November 1979. The patient was placed on

therapy with a saturated solution of potassium iodide,

because initial microscopic examination of the mold

suggested a morphology compatible with Sporothrixschenckii Hektoen et Perkins. On 16 November 1979,

the patient was scheduled for hospitalization to de-

bride the abscess (Fig. 1). Cultures obtained on 17

November 1979 and held for 6 weeks grew no fungi or

bacteria. On 19 November 1979, the wound appeared

clean and the patient was discharged. By 14 January

1980, the abscess had healed.

MATERIALS AND METHODS

Purulent material obtained from the gluteal abscess

was used to prepare both centrifuged and uncentri-

fuged smears. Smears were stained by both the Gram

and Wright methods. Potassium hydroxide and direct

wet preparations were also made of abscess material.

Specimen material was placed on various media: 5%

sheep blood agar, chocolate agar, Trypticase soy agar

(BBL Microbiology Systems) pour plates, potato dex-

trose agar, Sabouraud dextrose agar, cornmeal agar,

and Middlebrook 7H10 medium. The organism was

subsequently sent to other institutions for identifica-

tion, where the media employed were 2% malt-extract

agar, asparagine-yeast agar, oatmeal agar, and potato

flakes agar. All cultures were incubated at 30 and 350C

for as long as 6 weeks. Fragments taken directly from

mold growth on the various media and scotch-tape

preparations were mounted in lacto-phenol cotton blue

and studied by transmitted-light microscopy.The routine N-acetyl cysteine-NaGH digestion pro-

cedure of Kubica and Dye was utilized for preparationof the purulent exudate (10). Formalinized paraffin cell

blocks of the purulent exudate were also prepared bythe method of the Armed Forces Institute of Pathology

(2). All staining procedures were performed by stan-

dard methods (11).

RESULTS

Direct, centrifuged and uncentrifuged smears

stained with Gram and Wright strains and KOH

and wet preparations revealed no microorga-

TABLE 1. Colonial appearance and pigmentationcharacteristics of P. hoffmannii on various media

Mediuma Incubation Macroscopic appearanceTemp (TC)SBA 35 Tan, wrinkled; velvety

surface textureCA 35 Tan, wrinkled; velvety

surface textureTSA 35 Yeast-like with a narrow,

filamentous edge; yellow-orange-salmon hue

PDA 35 Yeast-like, becomingwooly, amber-colored;brownish pigment onreverse

SDA 30 Glabrous and heaped;cinnamon-colored withdiffused brown pigmenton reverse

M7H10 30 Pigmentation distinctivelybrowner than on othermedia

a SBA, 5% sheep blood agar; CA, chocolate agar;TSA, Trypticase soy agar; PDA, potato dextrose agar;SDA, Sabouraud dextrose agar; M7H10, Middlebrook7H10 medium.

nisms from the specimens of 7 and 13 November1979. Fungal growth appeared on most culturemedia within 3 to 6 days. Growth was noted tobe much slower when the organism was subcul-tured onto cornmeal agar and potato dextroseagar for the enhancement of conidiation.

Colonial morphology and pigment productionwere distinctive for each medium employed andat different temperatures (Table 1). Generally,colonial growth was slow, e.g., 3 to 4 cm indiameter after 14 days on potato dextrose agar at25°C (Fig. 2).

Microscopic descriptions are based on iso-lates growing on potato flakes agar at 25°C. Thefungus consisted of masses of moniliaceous,septate hyphae of two sizes. One form wasbroad and appeared to have areas of bulging; thesecond form appeared to be thin and delicate.Typically, packed strands of aerial hyphae werepresent. Conidiophores were simple, smooth,and mostly hyaline in color. Conidiogenous cellswere cylindrical phialides, formed singly, hya-line, and measured 0.7 to 1.7 by 0.6 to 29 p.rmwithout collarettes (Fig. 3). As the culturesaged, the hyphae, conidiophores, and phialidesdarkened in color to a pale brown. Numerousphialoconidia were seen which were hyaline,nonseptate, and smooth walled and measured0.6 to 2.3 by 2.2 to 6.1 p.m. The conidia had aslightly curved appearance and tended to aggre-gate in masses (Fig. 4). Most of the conidia wereformed at the tips of the conidiogenous cells, butsome appeared to have arisen directly from

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GLUTEAL ABSCESS CAUSED BY P. HOFFMANNII 183

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FIG. 2. P. hoffmannii. Colonial appearance on Sa-bouraud dextrose agar after 2 weeks at 25°C.

hyphal cells. Also observed were numerous co-nidia which appeared to be yeast-like and bud-ding, giving rise to additional conidia.

The mold was identified as Aureobasidiumpullulans (de Bary) Arnaud. Because of theclinical significance and non-dematiaceous ap-pearance of the fungus at the Woodland Cliniclaboratory, the isolate was sent to several addi-tional mycologists and was reported uniformlyas a species of the genus Acremonium Link. Theisolate was finally sent to W. Gams (Centraal-bureau voor Schimmelcultures, Baarn, TheNetherlands), an international authority onAcremonium, for identification. Dr. Gams con-cluded that the isolate fit perfectly the P. hoff-mannii aggregate and that the erect phialidescharacteristic of Acremonium were entirely ab-sent. The fungus is now maintained as MSU 81-33 (Department of Microbiology, Montana StateUniversity) and NCMH 1039 (North CarolinaMemorial Hospital, Chapel Hill, N.C.).

Retrospectively, an N-acetyl cysteine-NaOHdigestion-decontamination procedure was per-formed in the hope of finding hyphae in thepurulent material sent to the laboratory in No-vember, 1979, which had been refrigerated for 3months (10). Hyphal elements were seen in thedirect wet preparation from the specimen bothbefore and after the buffer was added and aftercentrifugation. Hyphal elements in the sediment

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FIG. 3. P. hoffmannii. Hyphae, conidiophores,phialides, and conidia. Culture grown on potato dex-trose agar at 25°C. (x100)

FIG. 4. P. hoffmannii. Hyphae, conidiophores,phialides, and conidia. Culture grown on potato dex-trose agar at 25°C. (x250)

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184 RINALDI, MCCOY, AND WINN

appeared gram negative after being Gramstained under appropriate controls (3, 9). Cul-tures of the sedimented material grew out P.hoffmannii on 9 February 1980. A formalinizedparaffin cell block was made from 20 ml of therefrigerated purulent material. Moniliaceous hy-phae were observed in sections of this fixedmaterial stained with periodic acid-Schiff andGomori methenamine silver strains (2).

DISCUSSIONThe numbers and kinds of fungi causing hu-

man and animal mycoses are increasing in con-temporary medicine. The tremendous advancesin medical technology, while prolonging life andalleviating suffering, have also ushered in theage of "opportunistic" infectious diseases. Fun-gi considered to be saprobes or plant pathogensare increasingly being implicated as etiolog-ical agents in humans whose immunologicaldefenses have been compromised by other, un-derlying chronic diseases or by therapeutic mo-dalities which are cytotoxic and immunosup-pressive and alter the proper function of theimmune response (15). Although the patient inthis report was not overtly immunocompro-mised, she was elderly and had experienced anepisode of pneumonia of undetermined etiologywhile traveling abroad. The mycotic abscessdeveloped at the site of multiple injections ofantimicrobial agents for treatment of the respira-tory illness. We have no knowledge of theaseptic conditions or techniques utilized in theadministration of these injections. If the injec-tion equipment was contaminated with P. hoff-mannii, it is conceivable that the patient mayhave been infected via the administration of theagents for treatment of the pneumonia. Alterna-tively, the organism may have gained entranceto the tissue secondarily via the sites of traumainduced by multiple injections.The etiological agent of this mycosis repre-

sents a fungal complex, the P. hoffmannii aggre-gate. This aggregate is heterogeneous, with nor-mally somewhat curved conidia and pinkishcolonies. The genus Phialophora has been de-fined differently by various authorities, withseveral excellent reviews of the genus elucidat-ing the problems in dealing with the P. hoffman-nii group in particular (5, 6, 8, 12, 13, 17, 20-25).The work of Schol-Schwarz (17) showed thatspecies in this genus may produce phialides withstraight (parallel-walled) collarettes, e.g., cylin-drical phialides which merge into collaretteswhich lack a constriction. Cole and Kendrick (6)consider that the genus Phialophora is definedby species possessing flask-shaped phialideswhich demonstrate a definite constriction at thebase of the collarette. Unlike Schol-Schwarz,Cole and Kendrick concluded that species of

Phialophora do not produce chlamydoconidia.The latter authors maintained the genus Margar-inomyces Laxa for fungi which form cylindricalphialides merging into nonconstricted collar-ettes.

Phialophora hoffmannii was originally de-scribed in 1939 by Beyma as Margarinomyceshoffmannii Beyma (21). Beyma also describedseveral other species during this period (23)which all closely resembled his M. hoffmannii.In 1970, Schol-Schwarz thought that many ofBeyma's various species belonged to what shetermed the P. hoffmannii group. She concludedthat P. hoffmannii, P. luteo-viridis (Beyma)Schol-Schwarz, and P. mutabilis (Beyma)Schol-Schwarz were distinct species of thisgroup (17). Due to the presence of cylindricalphialides with nonconstricted collarettes, Coleand Kendrick would maintain these fungi inMargarinomyces, the genus in which they wereoriginally described by Beyma (6, 21, 24).McGinnis, after studying the type cultures of P.hoffmannii, P. aurantiaca Beyma (a later syn-onym of P. hoffmannii [17]), P. luteo-viridis, andP. mutabilis, considered them to be the sameand placed them into synonymy with P. hoff-mannii (12).W. Gams (personal communication to M. R.

McGinnis, 1980) felt that organisms which fit thedescription of P. hoffmannii but turn brown dueto the production of chlamydoconidia should becalled P. mutabilis. The isolate reported hereturned brownish but did not show brown cells.Because most isolates of P. hoffmannii are notusually dematiaceous but are pale pink andproduce phialides with nonflared collarettes,they closely resemble species of Acremonium.There is little doubt that this fungal aggregateneeds more intensive study. For the present, wehave elected to call our isolate P. hoffmannii.There have been other reports of human in-

fections with members of the P. hoffmanniiaggregate. These include mycotic keratitis, en-docarditis, and unspecified cases of phaeohy-phomycosis (12, 14, 17, 18). This report repre-sents, so far as we can ascertain, the firstdocumented description of a cutaneous abscesscaused by P. hoffmannii. Because our isolatelacked a dematiaceous appearance both in vitroand in vivo, we are reluctant to term this diseasephaeohyphomycosis (1).This case is of interest in that the etiological

agent is not a commonly encountered humanpathogen; it usually causes infection only in adebilitated host. The infection may have result-ed from an accepted medical procedure in arelatively uncompromised host. The organismcould not be demonstrated in clinical specimensby routine staining procedures unless the speci-men was digested or made into a paraffin block.

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GLUTEAL ABSCESS CAUSED BY P. HOFFMANNII 185

Apparently, debridement of the abscess wasefficacious, whereas the benefits of treatmentwith potassium iodide remain uncertain. Un-doubtedly, clinicians and microbiologists willencounter P. hoffmannii and other rarely isolat-ed fungi with increasing frequency in contempo-rary medicine.

ACKNOWLEDGMENTS

We appreciate the assistance of M. R. McGinnis in express-ing his expert opinion on the identity of our isolate and forarranging its identification by W. Gams. We are especiallygrateful to Debbie Powell for the excellent typing of themanuscript.

LITERATURE CITED

1. Ajello, L. 1975. Phaeohyphomycosis: definition and etiol-ogy, p. 126-133. In Proceedings of the Third InternationalConference on the Mycoses, scientific publication no.304. Pan American Health Organization, Washington,D.C.

2. Armed Forces Institute of Pathology. 1968. Manual ofhistologic and staining techniques, 3rd ed. McGraw-HillBook Co., New York.

3. Bartholomew, J. W. 1962. Variable influencing results,and the precise definition of steps in gram staining as ameans of standardizing the results obtained. Stain Tech-nol. 37:139-155.

4. Codish, S. D., and J. S. Tobias. 1976. Managing systemicmycoses in the compromised host. J. Am. Med. Assoc.235:2132-2134.

5. Cole, G. T. 1978. Conidiogenesis in the black yeasts, p.66-78. In Proceedings of the Fourth International Confer-ence on the Mycoses, scientific publication no. 356. PanAmerican Health Organization, Washington, D.C.

6. Cole, G. T., and B. Kendrick. 1973. Taxonomic studies ofPhialophora. Mycologia 65:661-668.

7. Fraser, D. W., J. I. Ward, L. Ajello, and B. D. Plikaytis.1979. Aspergillosis and other systemic mycoses. Thegrowing problem. J. Am. Med. Assoc. 242:1631-1635.

8. Gams, W., and V. Holubova-Jechova. 1976. Chloridiumand some other dematiaceous hyphomycetes growing ondecaying wood. Stud. Mycol. 13:59-72.

9. Hucker, G. J., and H. C. Conn. 1923. Methods of gramstaining. Tech. Bull. N.Y. State Agric. Exp. Stn. no. 93.

10. Kubica, G. P., and W. E. Dye. 1967. Laboratory methodsfor clinical and public health mycobacteriology. U.S.Public Health Service publication no. 1547. U.S. PublicHealth Service, Washington, D.C.

11. Lillie, R. D. 1954. Histopathologic technics and practicalhistochemistry. The Blakiston Co., Inc., New York.

12. McGinnis, M. R. 1978. Human pathogenic species ofExophiala, Phialophora, and Wangiella, p. 37-59. InProceedings of the Fourth International Conference onthe Mycoses, scientific publication no. 356. Pan AmericanHealth Organization, Washington, D.C.

13. Moreau, C. 1963. Morphologie comparee de quelquesPhialophora et variations du P. cinerescens. Rev. Mycol.(Paris) 28:260-276.

14. Pierach, C. A., G. Gulmen, G. Jeelani Dhar, and J. C.Kiser. 1973. Phialophora mutabilis endocarditis (letter).Ann. Intern. Med. 79:900-901.

15. Purnendu, S., and D. B. Louria. 1980. Higher bacterialand fungal infections, p. 325-360. In M. H. Grieco (ed).,Infections in the abnormal host. Yorke Medical Books,New York.

16. Rippon, J. W. 1977. Pathogenesis and epidemiology ofopportunistic mycotic infections: a review. Am. J. Med.Technol. 43:226-228.

17. Schol-Schwarz, M. B. 1970. Revision of the genus Phialo-phora (Moniliales). Persoonia 6:59-94.

18. Slifkin, M., and H. M. Bowers, Jr. 1975. Phialophoramutabilis endocarditis. Am. J. Clin. Pathol. 63:120-130.

19. Utz, J. P. 1962. The spectrum of opportunistic fungusinfections. Lab. Invest. 11:1018-1025.

20. van Beyma Thoe Kingma, F. H. 1937. Beschreibung ein-iger neuer Pilzarten aus dem "Centraalbureau voorSchimmelcultures" Baarn (Holland). Zentralbl. Bakteriol.Parasitenkd. Infektionskr. Hyg. Abt. 2 Orig. Reihe A96:411-432.

21. van Beyma Thoe Kingma, F. H. 1939. Beschreibung ein-iger neuer Pilzarten aus dem "Centraalbureau voorSchimmelcultures" Baarn (Holland). V. Mitteilung. Zen-tralbl. Bakteriol. Parasitenkd. Infektionskr. Hyg. Abt. 2Orig. Reihe A 99:318-394.

22. van Beyma Thoe Kingma, F. H. 1940. Beschreibung ein-iger neuer Pilzarten aud dem Centraalbureau voor Schim-melcultures, Baarn (Nederland). VIII. Mitteilung. An-tonie van Leeuwenhoek J. Microbiol. Serol. 6:263-290.

23. van Beyma Thoe Kingma, F. H. 1943. Beschreibung der imCentraalbureau voor Schimmelcultures vorhadenen Artender Gattungen Phialophora Thaxter und MargarinomycesLaxa, Nebst Schiussel zu ihrer Bestimmung. Antonie vanLeeuwenhoek J. Microbiol. Serol. 9:51-76.

24. van Beyma Thoe Kingma, F. H. 1944-1945. Beschreibungeiniger neuer Pilzarten aus dem Centraalbureau voorSchimmelcultures, Baarn (Nederland). VIII. Mitteilung.Antonie van Leeuwenhoek J. Microbiol. Serol. 10:41-56.

25. Wang, C. J. K. 1965. Fungi of pulp and paper in NewYork. Tech. Publ. State Univ. Coll. For. Syracuse Univ.no. 87.

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