Treatment-resistant Scopulariopsis brevicaulis infection after filler injection.

Sir, Scopulariopsis, which is a genus of non-dermatophytic filamentous fungi, contains a number of common sa-prophytic fungi found in soil, vegetables, air, and organic waste. To date, eight species of Scopulariopsis have been reported to cause human infections. Of these, S. brevi-caulis is the most common; although is not generally considered to be a skin pathogen, the organism is isolated relatively frequently from onychomycosis patients (1). However, deeper cutaneous infection caused by S. brevi-caulis is extremely rare. We describe here a woman with treatment-resistant S. brevicaulis facial infection after a filler injection performed by an unlicensed practitioner. A 42-year-old woman presented in June 2008 with an ulcer covered by a black crust and surrounding palpable tender no-dules on the right temple (Fig. 1). In September 2006, she had received collagen injections into both temples, administered by an unlicensed practitioner. About 6 months later, she detected palpable nodules on both temples. She visited the unlicensed practitioner again, and received intralesional injections of an unknown material (described as a neutralizing agent) into both temples. Thereafter, her face became gradually more swollen, and an ulcer developed on her right temple. The patient was otherwise healthy, and routine laboratory tests, including blood tests and a chest roentgenogram, yielded data within normal limits. A skin biopsy was performed of a palpable nodule beside the crusted ulcer. Histology disclosed numerous branching septated hyphae and conidia in the deep dermis and subcutaneous fat (Fig. 2a). Fungal culture revealed entire-edged flat colonies with powdery, buff-to-brown, rugose surfaces. The reverse of the specimen culture was more waxy and yellow-white in colour. Lactophenol cotton blue mounts revealed numerous branching and septated hyphae with conidiophores and conidia in basipetal chains (Fig. 2b). As a Scopulariopsis infection was suspected, internal transcribed spacer (ITS) sequencing was performed to identify the isolate. An ABI PRISM 3130xl genetic analyser (Applied Biosystems, Foster City, CA, USA) and a Big-Dye Terminator Cycle Sequencing kit (Applied Biosystems) were employed. We found 100% homology with S. brevicaulis IFM 54315 (GenBank accession no. AB363754) and 99.5% (593 bp/596 bp) homology with S. brevicaulis CTSP F6 (GenBank accession no. EU862178) (2). Because the species showing the next-best homology (98.7%) was S. flava (GenBank accession no. AY494711), we identified the isolate as S. brevi-caulis (Fig. 3S, Treatment with itraconazole (200 mg daily) and terbinafine (250 mg daily) was commenced, but, after one week, the crusted ulcer was much enlarged. We decided to …