Cutaneous Protothecosis
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Protothecosis is an uncommon infection with an achlorophyllic algae of the genus Prototheca that may present as a localized infection of the skin, olecranon bursitis, or disseminated infection.
Localized infection of the skin is most common and typically results from primary inoculation through a wound or abrasion. In immunocompromised individuals, infection with Prototheca can become widespread. Currently, six species are included in the genus Prototheca: Prototheca wickerhamii, Prototheca zopfii, Prototheca blaschkeae, Prototheca cutis, Prototheca ulema, and Prototheca stagnora. The first four species are known to cause infections in humans, most commonly P wickerhamii. Prototheca infections have also been reported in cattle, cats, and dogs, with boxer dogs being the most represented canine breed noted to have cutaneous Prototheca infection. [1]
Prototheca is an achlorophyllic variant of the green alga Chlorella. The organism is ubiquitous but especially prevalent in aqueous environments. Infection usually results from inoculation into the dermis or subcutis by a penetrating injury associated with contaminated or swampy water. Traumatic inoculation with no water exposure has also been reported. [2] Infection has also been described as a complication following surgery. [3, 4] Person-to-person transmission has not been reported, but Prototheca has been cultured from underneath fingernails as well as from other cutaneous sites in healthy individuals.
When healthy individuals become infected, the organism has low virulence and may remit on its own without treatment. Reported cases of protothecosis are more commonly described in patients who are immunosuppressed, have a hematologic malignancy, or a history of organ transplantation. The more widespread use of immunosuppressive drugs also increases the risk of protothecosis infections. [5] Of all possible immunosuppressants, glucocorticoids, whether topically applied, taken orally, or locally injected, are the most specifically associated with the onset of protothecosis. [6] In healthy individuals, the infection is localized and curable, but cases of disseminated disease in individuals who are severely immunocompromised can be fatal. Cases of disseminated disease have involved the blood, the peritoneum, the GI tract, the liver, and the meninges.
Infection is usually caused by P wickerhamii. Less commonly, infection occurs with P zopfii. Prototheca is ubiquitous in the environment. It has been cultured from a wide variety of aqueous sources, including lakes, streams, ponds, and even tap water. Prototheca species have also been cultured from animal feces, soil, and a variety of other sources.
This organism is widely encountered in the environment, but it does not produce infection in most individuals. Most reported cases have occurred in patients who are severely immunosuppressed (eg, long-term immunosuppression for organ transplantation, [7, 8] autoimmune disease, graft versus host disease, chemotherapy or radiation therapy, [9] AIDS/HIV infection, [10, 11, 12] diabetes mellitus, [13] chronic renal failure, or Cushing disease). Another association reported included hypogammaglobulinemia (most likely resulting from common variable immunodeficiency. [14]
United States
Protothecosis is a rare infection, with the majority of reports involving the skin and nails. [15] Most cases in the United States are from the Southeast, although cases from virtually all geographic regions have been reported.
International
Protothecosis is seen worldwide, with cases reported on every continent except Antarctica. [6]
No racial predilection is noted.
No sexual predilection is evident.
Protothecosis typically affects those older than 30 years or elderly persons, although pediatric cases have been reported.
Patients with localized disease have an excellent prognosis and can expect cure. The prognosis of patients with severe disease and immunosuppression is poor.
In immunocompetent individuals, the infection usually remains confined to the skin at the site of inoculation. Olecranon bursitis can develop from protothecosis. Rarely, tenosynovitis can occur secondary to protothecosis and has been reported following injection of a sclerosing agent for varicose vein treatment. [16] Infection of a corneal graft has been reported. [17]
Rare cases of systemic infection occur almost exclusively in patients who are severely immunocompromised, as in patients receiving chemotherapy, or immunosuppressed patients, such as those on infliximab. Involvement of the meninges has been reported in a few cases of patients with AIDS.
Immunocompromised patients as well as healthy individuals should avoid bathing or swimming in swampy or stagnant bodies of water. Individuals diagnosed with prothecosis should undergo evaluation for underlying immunosuppression if an obvious predisposing factor is not already known.
Papadogiannakis EI, Velonakis EN, Spanakos GK, Koutinas AF. Cutaneous disease as sole clinical manifestation of protothecosis in boxer dog. Case Rep Vet Med. 2016 Feb 02. 2016:[Full Text].
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Khoury JA, Dubberke ER, Devine SM. Fatal case of protothecosis in a hematopoietic stem cell transplant recipient after infliximab treatment for graft-versus-host disease. Blood. 2004 Nov 15. 104(10):3414-5. [Medline].
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Torres HA, Bodey GP, Tarrand JJ, Kontoyiannis DP. Protothecosis in patients with cancer: case series and literature review. Clin Microbiol Infect. 2003 Aug. 9(8):786-92. [Medline].
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Kwong JC, Ward PB, Johnson PD. Cutaneous protothecosis in a patient with hypogammaglobulinemia. Med Mycol Case Rep. 2013 Jun 20. 2:132-3. [Medline]. [Full Text].
Zhang QQ, Li L, Zhu LP, et al. Cutaneous protothecosis in patient with diabetes mellitus and review of published case reports. Mycopathologia. 2012 Mar. 173(2-3):163-71. [Medline].
Lee JS, Moon GH, Lee NY, Peck KR. Case report: Protothecal tenosynovitis. Clin Orthop Relat Res. 2008 Dec. 466(12):3143-6. [Medline].
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Thomas N Helm, MD Clinical Professor of Dermatology and Pathology, University of Buffalo, State University of New York School of Medicine and Biomedical Sciences; Director, Buffalo Medical Group Dermatopathology Laboratory
Thomas N Helm, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society of Dermatopathology
Disclosure: Nothing to disclose.
Julia L Accetta Tulane University School of Medicine
Disclosure: Nothing to disclose.
David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for MOHS Surgery, Association of Military Dermatologists, Phi Beta Kappa
Disclosure: Nothing to disclose.
Christen M Mowad, MD Professor, Department of Dermatology, Geisinger Medical Center
Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, Noah Worcester Dermatological Society, Pennsylvania Academy of Dermatology, American Academy of Dermatology, Phi Beta Kappa
Disclosure: Nothing to disclose.
William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine
William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology
Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD.
Barbara R Reed, MD Clinical Professor, Department of Dermatology, Dermatology Service, Denver Veterans Affairs Medical Center, University of Colorado Health Sciences Center; Consulting Staff, Denver Skin Clinic
Disclosure: Nothing to disclose.
Earl J Glusac, MD Professor, Departments of Pathology and Dermatology, Yale University School of Medicine
Earl J Glusac, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.
Jon H Meyerle, MD Assistant Professor, Department Dermatology, Uniformed Services University of the Health Sciences; Assistant Professor, Department of Dermatology, Johns Hopkins University School of Medicine; Chief, Immunodermatology, Walter Reed National Military Medical Center
Jon H Meyerle, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Sigma Xi
Disclosure: Nothing to disclose.
Sarah K Taylor, MD Staff Physician, Eisenhower Army Medical Center Dermatology, Ft Gordon
Disclosure: Nothing to disclose.
Ashley R Mason, MD Dermatopathology Fellow, Department of Dermatology, Yale University School of Medicine
Ashley R Mason, MD is a member of the following medical societies: American Academy of Dermatology and International Society of Dermatopathology
Disclosure: Nothing to disclose.
Cutaneous Protothecosis
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