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Outbreak of Invasive Mycoses Caused by Paecilomyces lilacinus from a Contaminated Skin Lotion

Bernd Orth, MD; Reno Frei, MD; Peter H. Itin, MD; Michael G. Rinaldi, PhD; Bruno Speck, MD; Alois Gratwohl, MD; and Andreas F. Widmer, MD, MS
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From University Hospital, Basel, Switzerland; and the University of Texas Health Science Center, San Antonio, Texas. Acknowledgments: The authors thank the following persons from the University Hospital, Basel, Switzerland: J. Wuhrmann, H. Leisinger, C. Grasslin, K. Haupt, and the staff of the hematology-oncology isolation and bone marrow transplantation unit; A. Tichelli, M. Bargetzi, J. Passweg, and the staff of the Division of Hematology; W. Stauffacher and M. Uhr of the Department of Internal Medicine; C. Haberthur and I. Fey of the Division of Clinical Epidemiology; T. Renz, G. Dietsche, and the staff of the Bacteriology Laboratory; W. Zimmerli of the Division of Infectious Diseases; and H.L. Kain, J. Messerli, and the staff of the Clinics of Ophthalmology. The authors also thank G. Schar of the Institute of Medical Microbiology, University of Zurich, Zurich, Switzerland, and J. Pettypool for secretarial support. Requests for Reprints: Andreas F. Widmer, MD, MS, Division of Clinical Epidemiology, University Hospital, Petersgraben 4, CH-4031 Basel, Switzerland. Current Author Addresses: Dr. Orth: Division of Hematology, Klinik Bavaria, An der Wolfsschlucht 1-2, Kreischa bei Dresden 01731, Germany.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1996;125(10):799-806. doi:10.7326/0003-4819-125-10-199611150-00003
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Background: Invasive mycoses are an important cause of illness and death in immunocompromised patients. Infections with molds other than aspergilli have been increasingly seen in patients with hematologic cancers, but epidemics of these infections have not yet been reported.

Objective: To describe an outbreak of invasive mycoses with Paecilomyces lilacinus in severely neutropenic patients.

Design: An outbreak investigation.

Setting: The hematology-oncology isolation and bone marrow transplantation unit of the University Hospital, Basel, Switzerland.

Patients: 25 consecutive patients admitted between 17 August 1993 (the date of the first manifestation of P. lilacinus infection) and 31 October 1993 (when the unit was closed).

Measurements: Clinical and microbiological data, including histologic findings; cultures from several patient sites; and environmental examinations of potential airborne, parenteral, enteric, and horizontal routes of transmission. Infections were defined by the isolation of P. lilacinus from clinically evident skin eruptions.

Results: 12 of the 25 patients (48%) were infected or colonized. Nine patients (36%), including all bone marrow transplant recipients, had documented invasive P. lilacinus infections. All 9 infected patients had papular, pustular, or necrotic skin eruptions. Two patients with severe graft-versus-host disease died with refractory fungal disease; 1 also had microbiologically documented endophthalmitis and kidney infiltrates. Seven affected patients no longer had P. lilacinus after recovery of bone marrow function. The organism was resistant in vitro to amphotericin B, itraconazole, and fluconazole. Patients did not respond clinically to these agents. The outbreak was ultimately traced to a contaminated, commercially available, pharmaceutically prepared skin lotion. The outbreak ended after the skin lotion was recalled and has not recurred after a follow-up period of 2 years.

Conclusion: Contaminated skin lotion is a potential cause of opportunistic fungal infections in immunocompromised hosts. Paecilomyces lilacinus is a common saprophytic mold that can cause, by direct cutaneous inoculation, invasive infections associated with illness and death.


Grahic Jump Location
Figure 1.
Discrete erythematous papulovesicular lesions in patient 5.
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Grahic Jump Location
Figure 2.
Necrotizing papulovesicular lesions in patient 7.
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Figure 3.
Endophthalmitis and appearance of several chorioretinitic lesions in patient 3.
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Figure 4. Several inflammatory cells can be seen. (Periodic acid-Schiff stain; original magnification, × 32.).
Hyphae in the stratum corneum epidermidis and the deep dermis in patient 3.
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