|Year : 2021 | Volume
| Issue : 2 | Page : 51-58
Phaeohyphomycosis and role of internal transcribed spacer
Lokeshwari Gopal1, G Balajee1, KS Mouleeswaran2, Anupma Jyoti Kindo3, Subramanian Swaminathan4, G Srividhya4, Selva Seetharaman5, Arun Kumar6, Muthukumar Periasamy7, Nigel Peter Symss8
1 Department of Microbiology, Gleneagles Global Health City, Chennai, Tamilnadu, India
2 Department of Pathology, Gleneagles Global Health City, Chennai, Tamilnadu, India
3 Department of Microbiology, SRMC and RI, Sri Ramachandra University, Chennai, Tamilnadu, India
4 Department of Infectious Disease, Gleneagles Global Health City, Chennai, Tamilnadu, India
5 Department of Plastic, Cosmetic and Aesthetic Surgery, Gleneagles Global Health City, Chennai, Tamilnadu, India
6 Department of Plastic, Cosmetic and Reconstructive Surgery, Gleneagles Global Health City, Chennai, Tamilnadu, India
7 Department of Nephrology, Cosmetic and Reconstructive Surgery, Gleneagles Global Health City, Chennai, Tamilnadu, India
8 Department of Neurosurgery, Gleneagles Global Health City, Chennai, Tamilnadu, India
|Date of Submission||19-Oct-2021|
|Date of Decision||01-Nov-2021|
|Date of Acceptance||25-Nov-2021|
|Date of Web Publication||27-Jan-2022|
Dr. Lokeshwari Gopal
Department of Microbiology, Gleneagles Global Health City, No. 439, Cheran Nagar, Perumbakkam, Chennai - 600 100, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Phaeohyphymocosis is caused by a heterogeneous group of black-pigmented fungi. Clinical manifestations range from small localised subcutaneous lesion to life-threatening invasive and disseminated infection. With increase in immunocompromised patients due to various conditions, phaeoid fungus has gained its role as a pathogen in human diseases. There is no pathognomonic clinical or radiological feature to diagnose phaeohyphomycosis. Thus, the role of diagnostics in histopathology and microbiology is important in identification and diagnosis of this clinical condition. Specimens received for fungal identification were cultured on Sabouraud's Dextrose Agar with 10 mg/L Chloramphenicol (SCA) and identified by conventional methods. Few phaeoid fungi, which did not sporulate even after prolonged incubation under appropriate conditions in routine culture media, were identified by Internal Transcribed Spacer sequencing. Here, we present case series of five patients presented to our hospital with brain abscess, post traumatic wound, two post renal transplant recipients with skin and soft tissue infections, diabetes-associated soft tissue swelling and diagnosed with phaeohyphomycosis from 2017 to 2019.
Keywords: Curvularia hawaiiensis, Cladophialophora bantiana, internal transcribed spacer, Medicopsis romeroi, phaeohyphymocosis, rhytidhysteron rufulum
|How to cite this article:|
Gopal L, Balajee G, Mouleeswaran K S, Kindo AJ, Swaminathan S, Srividhya G, Seetharaman S, Kumar A, Periasamy M, Symss NP. Phaeohyphomycosis and role of internal transcribed spacer. J Acad Clin Microbiol 2021;23:51-8
|How to cite this URL:|
Gopal L, Balajee G, Mouleeswaran K S, Kindo AJ, Swaminathan S, Srividhya G, Seetharaman S, Kumar A, Periasamy M, Symss NP. Phaeohyphomycosis and role of internal transcribed spacer. J Acad Clin Microbiol [serial online] 2021 [cited 2022 May 23];23:51-8. Available from: https://www.jacmjournal.org/text.asp?2021/23/2/51/336591
| Introduction|| |
Infections caused by phaeoid fungi are broadly termed Phaeohyphomycosis and Chromoblastomycosis. Phaeohyphomycosis is subcutaneous and systemic infection, caused by phaeoid fungi existing in hyphal forms in tissues. Hyphomycetes such as Alternaria, Bipolaris, Curvularia, Cladophialophora, Exophiala, Exserohilum, Phialophora, Wangiella, Cladosporium, Chaetomium, Ochroconis species; Coelomycetes like Phoma species; Medicopsis romeroi can cause phaeohyphomycosis. Chromoblastomycosis is slowly progressing chronic cutaneous to subcutaneous lesion mostly involving exposed parts of the body with tendency to disseminate via lymphatic system. Chromoblastomycosis is caused by Cladophialophora carrrionii, Fonsecaea pedrosoi, Phialophora verrucosa, Rhinocladiella aquaspersa and is characterised by polymorphic, verrucoid, crusted or ulcerated lesions. The unique histopathological morphology in chromoblastomycosis is sclerotic or medlar bodies. Thus, disease caused by phaeoid fungi has been defined based on histopathological grounds rather than clinical entity. The case series described here are five different and rare phaeoid fungi with various clinical presentations such as localised cutaneous/subcutaneous lesions, post-traumatic wound infection and invasive cerebral phaeohyphomycosis. Some phaeoid fungi do not form typical structural characteristics required for micro and macroscopic identification under standard laboratory conditions. Internal Transcribed Spacer sequencing (ITS) plays a major role in identifying such non-sporulating phaeoid fungi. In rDNA gene complex of fungus, the ITS region is located between the 18S and 28S rRNA genes. The ITS region includes ITS1, 5.8SrRNA and ITS2 regions in order from 5' to 3'end.
| Methodology|| |
Clinical specimens received in the microbiology department for fungal cultures from 2017 to 2019 were subjected to 10% Potassium hydroxide mount (KOH) and culture on Sabouraud's Dextrose Agar with 10 mg/L Chloramphenicol (SCA) at 37°C and 25°C. Cultures incubated for three weeks. All the phaeoid fungi during this period were included in this study. Phaeoid fungi were identified by macroscopic morphology, lacto phenol Cotton blue mount and microscopic morphology.Phaeoid fungi which did not sporulate were incubated for 3 months and simultaneously banana peel culture was done to induce sporulation. ITS was performed for the identification of non-sporulating phaeoid fungi and speciation. Primers targeting ITS regions were:
ITS1 (5'-TCCGTAGGTGAACCTGCGG-3'); ITS2 (5'-GCTGCGTTCTTCATCGATGC-3');
ITS3 (5'-GCATCGATGAAGAACGCAGC-3'); ITS4 (5'-TCCTCCGCTTATTGATATGC-3'). GenBank Basic Local Alignment Search Tool was used to perform sequence homology search for species identification. All positive fungal cultures were correlated with histopathology findings.
A 30-year-old male from Jamshedpur (Jharkhand), a known case of systemic hypertension, Diffuse Proliferative Glomerulonephritis with acute kidney injury on haemodialysis and steroid therapy developed progressive right-sided hemiplegia, aphasia and 4–5 episodes of seizures was brought to our hospital in November 2018. Brain imaging in a tertiary care hospital revealed a Left frontotemporal space occupying lesion and differential diagnosis were pyogenic brain abscess/tuberculoma/neurocysticercosis/tumour. He was started on empirical anti-tuberculosis treatment and advised surgical excision. The patient was referred to our centre for further management. He was aphasic, right limbs paralysed and Glasgow Coma Scale was E4V2M6. He had left frontal, parietal intracranial lesions extending deeper to temporal regions [Figure 1]a. Left frontotemporal craniotomy, superficial abscess drainage and partial excision of capsule were done.
|Figure 1: (a) (Sagittal T2W1): MRI brain showing Left fronto-parietal abscesses extending to temporal region with irregular walls, central cystic areas and mass effects. (b) Potassium hydroxide mount: Septate hyphae with Cladophialophora like conidiation. (c) PAS stain: Septate, acute angle branching hyphae with bulbous ends. (d) lacto phenol cotton blue mount: Ellipsoidal conidia in long chains on undifferentiated hyphae|
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Pus was received in microbiology and histopathology departments. Gram smear showed moderate pus cells, septate hyphae and brown pigmented conidia in chains. Septate hyphae and conidia in chains were observed in KOH mount [Figure 1]b. Modified Ziehl–Neelsen stain was negative for Acid Fast Bacilli (AFB). Gene Xpert MTB/RIF was negative for Mycobacterium tuberculosis complex.
Smears in histopathology showed septate acute angle branching hyphae with bulbous ends and occasional pigmentation in a background of necrosis, acute inflammation and haemorrhage [Figure 1]c.
Aerobic, Anaerobic, and AFB culture were negative. Black pigmented fungi grew on SCA at 37°C and 25°C by day 4. Colonies: Smooth, folded, velvety, dark olive-black, compact with entire edges on obverse; nondiffusible olivaceous-black pigment on reverse. Microscopically pale olivaceous, ellipsoidal conidia in long, coherent, poorly branched, sessile, lateral or terminal chains on undifferentiated hyphae was observed [Figure 1]d. The fungus was thermo-tolerant (growth at 42°C positive) and was identified as Cladophialophora bantiana.
Patient was started on Voriconazole 400 mg on day 1 and 300 Q12H from day 2. Immediate post-operative period was uneventful. Patient left against medical advice on day 5 and lost follow-up.
A 34-year-old male, a police constable from Nellore district presented with polytrauma following train accident in December 2018. He had compound fracture right proximal femur, right proximal tibia, closed degloving injury right thigh, multiple rib fractures, right pneumothorax and right lung lower lobe consolidation. Open reduction and internal fixation (ORIF) with intra-medullary nailing was done for femur fracture and ORIF for fracture tibia. Two weeks later, he presented with multiple wounds in the right thigh with serous discharge not healing with regular cleaning and dressing [Figure 2]a. Intraoperatively, extensive deep tissue involvement was observed. Wound debridement followed by VAC dressing was done.
|Figure 2: (a) Multiple right thigh non– healing wounds. (b) Potassium hydroxide mount: Septate hyphae with acute angled branching. (c) PAS stain: Branching septate hyphae with bulbous ends. (d) lacto phenol cotton blue mount: Brown septate hyphae and conidiophores with sympodially arranged conidia. (e) Germ tube test lacto phenol cotton blue mount: Germ tubes parallel to long axis of the conidium at both ends. (f) Post operative wound-healed status|
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Bacterial infection was suspected and tissue sent to Microbiology requesting Gram smear and aerobic culture. Routine practice in our laboratory is to do fungal culture for all tissue samples, which helped to arrive at pathogen-directed management.
Gram stain showed occasional pus cells and no organisms. Aerobic culture for bacteria was negative. Fungal culture revealed growth on 3rd day at 37°C and 25°C. Based on this report, repeat wound debridement was performed. Specimen was received for fungal smear, fungal culture and histopathology. KOH mount was positive for acute angle branching septate hyphae [Figure 2]b. Histopathology showed branching septate hyphae with tissue and angioinvasion [Figure 2]c.
Fungal growth was observed on day 3 which matured by day 9. Colonies were black, spreading and powdery to hairy on obverse with black pigment on reverse. Microscopically: Hyphae-brown and septate; conidiophores-brown, erect, unbranched, apically flexuose with flat conidial scars on the edges; Conidia–proconidia (conidia produced through a pore in the conidiophore), smooth and thick-walled, brown, arranged sympodially, with 3-5-7 distosepta (conidia subdivided by inner wall layer only); cylindrical to cigar-shaped [Figure 2]d. Germ tubes were observed parallel to the long axis of the conidium at both ends in Germ tube test [Figure 2]e.
The fungus was identified as Bipolaris species by conventional methods. ITS was performed in culture isolate for speciation and was identified as Curvularia hawaiiensis.
A month after polytrauma, the patient had decreased left eye vision (6/24) with painless corneal ulcer. Fungal culture from corneal scrapping grew a fungus with similar colony morphology as that of the right thigh specimen. Microscopically, non-sporulating brown pigmented septate hyphae were observed. Failure to sporulate might be due to prior antifungal therapy.
The patient was treated with Voriconazole 300 mg twice a day and 5% Natamycin followed by 1% Voriconazole eye drops for 3 months. His vision improved within 10 days of medical management.
After a month of antifungal therapy post debridement, right thigh wound was healthy, and repeat fungal culture was negative. Split Skin Graft was performed to close the debrided wound defect [Figure 2]f.
A 40-year-old male from Chennai, known Diabetic for 7 years presented to the plastic surgery department with right foot slow-growing, soft, painless swelling (4 cm × 4 cm) for 6 months [Figure 3]a. No history of trauma or penetrating injury. Intraoperatively, it was pus-filled soft swelling infiltrating the cutaneous nerve which was excised sparing the nerve [Figure 3]b. Pus and excised tissue were received in microbiology and histopathology departments.
|Figure 3: (a) 4 cm × 4 cm swelling in the dorso-medial aspect of right foot. (b) Intra operative– pus filled swelling infiltrating the cutaneous nerve. (c) SCA: Obverse-Grey floccose colonies. Figure (d) lacto phenol cotton blue mount: Smooth walled branching septate hyphae. (e) GMS stain: Slender branching septate hyphae|
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Gram stain and KOH mount showed septate hyphae. AFB culture was negative. Fungal culture at 25°C revealed fungal growth on day 3. Colonies on SCA were floccose with grey surface and white margin on obverse and black non-diffusible pigment on reverse [Figure 3]c. Microscopically, it was non-sporulating smooth walled branching septate hyphae; which was initially hyaline, changing brownish black by 3rd week [Figure 3]d.
Haematoxylin and Eosin (H and E) stain showed slender septate hyphae with focal superficial tissue invasion and no angio-invasion. Periodic acid–Schiff stain (PAS) and Grocott-Gomoris methenamine silver stain (GMS) were positive for fungal filaments [Figure 3]e.
Nucleic acid sequencing targeting the ITS of the ribosomal DNA identified this mould as Medicopsis romeroi.
The patient was treated with Itraconazole 200 mg twice daily for 6 weeks. The wound healed well in 3 months without any recurrence.
This is 56-year-old male, known diabetic, hypertensive, a renal transplant recipient with chronic allograft dysfunction on triple immunosuppressant presented 1½ year after transplant (December 2017) with slow-growing swelling (12 cm × 8 cm) over right elbow for 4 months, pain and pus discharge for 1 week and fever for a day [Figure 4]a. No history of trauma. Swelling was fluctuant and tender on palpation. Infected bursitis, tuberculosis and malignancy were the differential diagnosis.
|Figure 4: (a) Fluctuant swelling 12 cm × 8 cm posterior aspect of right elbow. (b) SCA: obverse-rugose brownish black colonies at 8 weeks of incubation. (c) lacto phenol cotton blue mount: Brown branching septate hyphae. (d) PAS stain: Thin septate hyphae with bulbous ends|
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Two soft tissue swellings measuring 15 cm × 13 cm and 4 cm × 4 cm in muscular plane were observed in the right elbow ultrasonogram (USG). Incision and drainage (I and D) of the abscess was done and pus sample received in microbiology and histopathology departments.
There were many pus cells and septate hyphae in Gram stain, septate hyphae in fungal smear. Aerobic culture grew Coagulase negative Staphylococcus. AFB culture was negative. Fungal culture at 25°C revealed fungal growth by day 5.
Macroscopically, Colonies at 2nd week were floccose and grayish-black turning dry, rugose brownish black at 8 weeks of incubation on obverse, and black on reverse [Figure 4]b. Microscopically, nonsporulating smooth walled brown branching septate hyphae with occasional chlamydospores were observed [Figure 4]c.
This non-sporulating fungus was identified as Rhytidhysteron rufulum by ITS at PGI Chandigarh.
H and E stain showed fibro connective tissue with multiple foci of acute necrotising granulomatous inflammation and thin septate hyphae. PAS and GMS were positive for septate hyphae [Figure 4]d.
The patient was treated with oral Itraconazole for 3 months. There was no recurrence of elbow swelling. However, 4 months later patient succumbed to Gram-negative sepsis.
This 55-year-old male, a Government employee from Virudachalam (Cuddalore) was a known diabetic, hypertensive, renal transplant recipient on immunosuppressant. He presented 1 year after transplant (September 2018) with a swelling of 1 month duration over lateral aspect of left knee. It was nontender, noninflamed, firm swelling gradually increasing in size to attain the size of 4 cm × 3 cm, which was excised.
Second presentation: Four months later (January 2019), he presented with swelling over medial aspect of the left knee of 1 month duration measuring 6 cm × 5 cm. The swelling was 36 cm × 26 mm in subcutaneous plane by USG. It was tender and inflamed swelling, which was excised.
Third presentation: 8 months later (September 2019), patient presented with right elbow firm, tender and inflamed swelling measuring 3 cm × 3 cm [Figure 5]a. Excision was done and the wound healed well [Figure 5]b.
|Figure 5: (a) 3 cm × 3 cm swelling over supero-medial aspect of right elbow. (b) Healed elbow. (c) Edematous foot with 1 cm × 1 cm ulcer with slough right foot corresponding to 3rd metatarsal. (d) Well healed foot wound|
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Fourth presentation: A month later (October 2019), patient presented with pain and discharge from the right foot of 1 month duration. On examination, the foot was edematous, 1 cm × 1 cm ulcer with slough corresponding to 3rd metatarsal bone [Figure 5]c. The patient had a history of thorn prick on his right foot 6 years back followed by chronic right foot ulcer for which he had undergone multiple wound debridements. On investigating, he had right foot 3rd and 4th toe proximal phalanx base and metatarsal head osteomyelitis. Wound debridement and sequestrectomy was performed. Postoperative wound healing was uneventful without any further recurrence [Figure 5]d.
The respective excised tissues during all presentations were received in Microbiology department. Aerobic culture in all samples except the second presentation was negative. The second presentation was left knee Staphylococcus aureus abscess. AFB culture was done only in the left knee tissue, which was negative. Fungal smear was negative in all samples. Fungal culture was positive in left knee and right elbow tissues on day 7 in SCA plates at 25°C. Fungal culture in right foot 3rd and 4th proximal phalanx and metatarsal head was negative.
Fungal colonies were floccose, greyish initially turning black on obverse and reverse as culture aged [Figure 6]a. Microscopically it was nonsporulating smooth walled branching septate hyphae [Figure 6]b.
|Figure 6: (a) SCA: Floccose greyish black on obverse and black on reverse. (b) lacto phenol cotton blue mount: Non-sporulating smooth walled branching septate hyphae. (c) PAS stain: Thin septate fungal hyphae with bulbous ends|
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Of multiple debridements performed, only left knee tissue was sent for histopathology. Cavitatory lesion with extensive necrosis, ill-defined granulomas and tissue invasive septate fungal hyphae with acute angle branching was observed [Figure 6]c.
This was a highly pigmented black fungi and was unidentifiable even with ITS.
| Discussion|| |
Cladophialophora bantiana brain abscess
C. bantiana is a remarkable neurotropic mould causing disease both in immunocompromised and immunocompetent individuals. It belongs to the order Chaetothyriales and is characterised by very long, coherent poorly branched conidia in chains and an absence of differentiated conidiophores. Cladophialophora species is found in the soil of Panama, Uruguay; saw dust mulch Heap, USA; stamp of Juniperus virginiana, USA; coal mine, Belgium and Turkey and hot water tub, Illinois, USA. A detailed environmental survey for Cladophialophora species is essential to understand exact epidemiology of the disease in India.
The portal of entry may be the lung but symptoms are confined to brain. Other routes of entry are direct brain inoculation following penetrating trauma, through paranasal sinus or extension from mastoid infection. Melanin production and thermotolerance (above 40°C) are attributed to its virulence.
The brain lesions were observed more in frontal region followed by parietal and occipital region. Our patient presented with fronto-parieto-temporal abscess.
Complete surgical removal of the encapsulated abscess whenever possible followed by antifungal therapy is the treatment for Cladophialophora cerebral phaeohyphomycosis. Among azoles, Itraconazole and Posaconazole have the best in vitro activity. Voriconazole has better central nervous system penetration, better bioavailability and plasma trough levels can be maintained with therapeutic drug monitoring. Isavuconazole reveals low MICs for Cladophialophora carrionii. Combination therapy with amphotericin B, flucytosine, caspofungin and terbinafine, or an extended spectrum triazole has been proposed in patients with multiple inoperable brain abscesses.
Overall mortality in Cladophialophora brain abscess is greater than 70%. Histopathology and culture-based diagnosis of any radiologically detected brain abscess at the earliest is essential for targeted therapy which definitely has an impact on better patient outcome.
Curvularia hawaiiensis (Bipolaris hawaiiensis) in posttraumatic wound
Curvularia hawaiiensis, a dematiaceous filamentous fungus is cosmopolitan in nature; present in plant debris and soil. Common Bipolaris species causing human infections are Bipolaris australiensis, B. hawaiiensis and B. spicifera. The phylogenetic analysis of genera Bipolaris and Curvularia resulted in re-alignment of several species and the above three Bipolaris species have been transferred to Curvularia since 2012. Infection with Curvularia is found both in immunocompetent and immunocompromised host.
Mold infections may follow traumatic injuries especially penetrating trauma with direct fungal inoculation at the site of injury and subsequent angioinvasion resulting in vessel thrombosis and tissue necrosis. Zygomycetes, Aspergillus spp., Fusarium spp. are commonly encountered in wounds following trauma and soil contamination (e.g., agricultural or automotive injuries) in general population. Acrophialophora spp. Alternaria spp., Beauveria spp., Bipolaris spp., Graphium spp., Paecilomyces spp., Penicillium spp., Pythium aphanidermatum, Scedosporium prolificans, Ulocladium spp. were isolated from wounds following military trauma.
So far, only one Post Road Traffic Accident Chronic Suppurative Otitis Media caused by Curvularia hawaiiensis in a young male treated with Itraconazole was reported. Ours' is a unique presentation of Curvularia in a post train accident wound.
Any post-traumatic wound with fungal infection needs repeated debridement and antifungal with good activity against specific fungi. Itraconazole, Voriconazole, Posaconazole and Amphotericin B have good activity against Bipolaris species.
Medicopsis romeroi soft tissue abscess
M. romeroi is a dematiaceous Coelomycete belonging to the order Pleosporales; formerly named as Pyrenochaeta romeroi. It is widely distributed in the environment and is found in soil, wood and plants of tropical areas-Africa, India and South America.
M. romeroi is known to cause black-grain Eumycotic Mycetoma. As in this study, nonmycetoma infections with branching dark pigmented hyphae in tissues without granules in immunocompromised patients have also been reported.
Clinical presentation of M. romeroi is usually subcutaneous lesion-nodular/cystic/verrucous plaque commonly involving exposed parts of lower limb. A few case reports have reported multiple discharging sinuses, discrete keratotic lesion and upper limb lesions.,,,,,,,, Risk factors were diabetes mellitus as in our patient,, immunosuppressed status including renal transplant,,,, IV canula in situ and Acute Lymphoblastic Leukemia. Mode of transmission could be from the soil, wood or plants via., minor trauma.
There is no standard therapy for M. romeroi infections. So far, itraconazole is being used in patients with M. romeroi Mycetoma. In a study by Sarah Abdalla Ahmed et al., M. romeroi from patients with phaeohyphomycosis showed lower MICs for amphotericin B with better patient outcome in contrast to H. Badali et al. Itaconazole, isavuconazole and posaconazole has potent activity against this isolate.
Rhytidysteron rufulum abscess
Rhytidysteron rufulum belongs to Ascomycota, Order Patellariales, class Dothideomycetes. This fungus was first reported by Chowdhary et al. in a post renal transplant recipient in 2008, followed by 9 cases were reported till date in India and one from Australia. Of these 11 patients-two were immunosuppressed, 2 were diabetic and 7 were immunocompetent. Chronic sub-cutaneous non tender nodule, nodulo-ulcerative lesion, crusted/ulcerated lesion or cystic swelling were the common clinical presentations.,,,,,,,,,
Patients with Rhytidysteron infection were treated with Itraconazole alone or surgical excision plus Itraconazole. Weekly intra-lesional liposomal Amphotericin B for non-responsive lesion was also effective. Wide surgical excision alone can be a cure if the patient is intolerant to antifungals. Outcome was good in immunocompentent patients.
In the present case series, we have reported second case of Rhytidysteron rufulum infection in post renal transplant recipient who was on triple immunosuppressants.
Case 5 discussion
This clinical presentation with recurrent fungal lesions over upper and lower extremities emphasis the importance of eliciting detailed clinical history of the patient including past history of any trivial trauma. Though the patient had multiple wound debridements in the past, sequestrectomy of right foot 3rd and 4th metatarsals which may be the focus of recurrent fungal lesions led to complete cure of the disease.
| Conclusion|| |
Diagnosis of phaeohyphomycosis needs a high degree of clinical suspicion and careful Mycological and Histopathological examination of clinical specimens. Identification of clinically relevant but unidentifiable fungi by conventional methods with a rapid and accurate amplification based ITS assay is extremely important in invasive fungal infections for appropriate pathogen based clinical management.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Dr Shivaprakash M Rudramurthy, Professor, Mycology Division, Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India for ITS identification of Rhytidysteron rufulum.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]