Apophysomyces variabilis Infections in Humans

Clinical and epidemiological characterization of dengue hemorrhagic fever cases in northeastern Brazil. To the Editor: The fungus Apo-physomyces elegans (order Mucorales) is a thermotolerant species that causes severe infections among humans. In contrast to other fungi that cause zy-gomycosis, which have a worldwide distribution and are rarely found in immunocompetent hosts, A. elegans has been reported mainly in areas with warm climates as an emerging pathogen that causes mostly cutaneous infections after injury to the skin (1). This fungus was discovered in 1979 (2) and until recently was considered the only species in the genus. A polyphasic study of clinical and environmental strains of A. elegans, including analysis of several genes, showed that the genus contained 4 well-characterized species (3). Of 16 isolates tested in this study, only 2 from soil in India were A. elegans. Most of the isolates were A. variabi-lis. The incidence of A. variabilis in humans is unknown and diffi cult to ascertain because most cases had isolates that were not properly preserved. These fungi usually cause necrotizing fasciitis, but rhino-orbito-cerebral or renal infections have also been reported (1). Whether these infections are produced by different Apophysomyces spp., have different responses to an-tifungal drugs, or have differences in virulence is unknown. To assess incidence of Apophy-somyces spp. in a tertiary hospital (Government Medical College Hospital , Chandigarh, India), which usually receives patients with zygomycosis, a retrospective study was conducted during November 2001–April 2009. Nine patients were identifi ed as having primary cutaneous zygomycosis. For 4 patients, fungal isolates were morphologically identifi ed as A. elegans. A description of clinical fi ndings, their management, and outcomes for these 9 patients has been reported (4). The 4 isolates were sent to the Universitat Rovira i Virgili (Reus, Spain) for molecular analysis. The internal transcribed spacer region of these isolates was sequenced and compared with those of type strains of Apophysomyces spp. Fungi were identifi ed by morphologic (Figure , panel A) and molecular analysis as A. variabilis (99.6%–99.7% sequence identity with sequence of type strain CBS 658.93 [FN556436]). GenBank accession nos. of the 4 isolates are FN813491, FN813490, FN556442, and FN813492. Another patient was also infected with A. variabilis fungi. The patient was a 45-year-old woman with diabetes from Derabassi (Punjab), India, who was hospitalized because of swelling in her right breast and blackening of overlying skin. A diagnosis of right breast gangrene was made. Therefore, local debridement …