AUTHOR=Zhou Ya Bin , Li Dong Ming , Houbraken Jos , Sun Ting Ting , de Hoog G. Sybren 

TITLE=Fatal Rhinofacial Mycosis Due to Aspergillus nomiae: Case Report and Review of Published Literature

JOURNAL=Frontiers in Microbiology

VOLUME=11

YEAR=2020

URL=https://www.frontiersin.org/journals/microbiology/articles/10.3389/fmicb.2020.595375

DOI=10.3389/fmicb.2020.595375

ISSN=1664-302X

ABSTRACT=<sec><title>Background</title><p>A 73-year-old female suffering from acute myeloid leukemia presented with progressive rhinofacial mycosis. Suspecting it to be mucormycosis, the antifungal amphotericin B (AMB) was administered empirically, but the patient did not respond as planned. The fungus was then isolated from the biopsied tissue and morphologically identified as a species of <italic>Aspergillus</italic>. Necrosis progressed and she died of cerebral hemorrhage. Since <italic>Aspergillus flavus</italic> is susceptible to AMB, and several other <italic>Aspergillus</italic> species can be misidentified as <italic>A. flavus</italic>, the observed resistance necessitated a re-examination of the fungal isolate.</p></sec><sec><title>Methods</title><p>The fungal strain was re-isolated and re-examined morphologically. Additionally, genomic DNA was extracted from the fungus and sequences were obtained from three genomic regions [the rDNA internal transcribed spacer (ITS) region, and portions of the β-tubulin and calmodulin genes] to more accurately identify this <italic>Aspergillus</italic> strain. Its antifungal susceptibility was assessed using multiple compounds and our findings were compared with literature data.</p></sec><sec><title>Results</title><p>The fungal culture again yielded an <italic>Aspergillus</italic> isolate morphologically identical to <italic>A. flavus</italic>. Molecular analyses, however, revealed the strain to be <italic>A. nomiae</italic>, a close relative of <italic>A. flavus</italic> in section <italic>Flavi</italic>, and it exhibited resistance to AMB. Reviewing the literature, only five other cases of <italic>A. nomiae</italic> infection in humans have been reported worldwide.</p></sec><sec><title>Conclusion and Clinical Importance</title><p>The rhinofacial mycosis of the patient was actually due to <italic>A. nomiae</italic>. The initial misidentification of the fungus, coupled with its resistance to AMB, could be the reason treatment did not help the patient. We postulate that clinical <italic>A. nomiae</italic> infections may be underreported and that accurate and speedy pathogen identification is important so that an effective antifungal regimen can be administered.</p></sec>