A 61-year-old female who had never smoked was referred to Osaka University Hospital with a productive cough, shortness of breath, and wheezing for 5 years. She had a high eosinophil range of 6–20% (normal, 2–4%) and transient recurrent infiltrates on serial chest X-rays. Eosinophilic pneumonia with bronchial asthma had been diagnosed and treatment with oral prednisolone resulted in the remission of symptoms for 2–3 weeks at a time.\nThe patient complained of up to 10 mL of sputum per day which was purulent, malodorous and sometimes formed mucoid plugs. She was prescribed with inhaled corticosteroids and long-acting beta-agonists. She was found to have bilateral coarse crepitations with biphasic polyphonic rhonchi on pulmonary examination. Blood cell analysis revealed a total leukocyte count of 7240 cells/μL; with 44.7% polymorphs, 36.8% lymphocytes, 5.5% monocytes, 11.9% eosinophils, and 1.1% basophils. The absolute eosinophil count was elevated at 861/μL. Serum biochemistry findings were unremarkable, and Aspergillus spp. IgG antibody was negative. Total IgE was within the normal range (70.36 IU/mL), but specific IgE for Aspergillus spp. was found to be positive.\nA chest X-ray showed infiltrates in the right lower lung (A), and computed tomography revealed bilateral dilation of the central bronchi in the right upper lobe (B). The involved bronchi contained hyperattenuating mucus. Bilateral central bronchiectasis was diagnosed. The patient was further investigated because saccular bronchiectasis is a feature of allergic bronchopulmonary aspergillosis (ABPA). Direct analysis of sputum samples using random sequencing (shotgun sequence) using a next-generation sequencer revealed fungal DNA. Aspergillus fumigatus was dominant and four other fungal sequences including Schizophyllum commune were found ().\nMicroscopic assessment of sputum was negative for acid-fast bacilli (AFB) and other bacteria. However, Charcot–Leyden crystals that are generated through the breakdown of eosinophils and hyphae were identified (C and D). Direct microscopy of KOH wet mounts of three consecutive sputum specimens and expectorated sputum/mucoid plugs revealed two types of septate and branching hyphae (A and B). Homogenized sputum and mucoid plugs inoculated onto Sabouraud's glucose agar (SGA) developed green and white colonies with a wooly texture after 4 days at 2 °C (C and D).\nOne of the fungi was morphologically identified as A. fumigatus (A and C), but the other (B and D) remained obscure. Therefore, DNA was extracted and the internal transcribed spacer region (ITS) and the D1/D2 region of large subunit rRNA gene were amplified by PCR. Direct sequencing of the PCR products showed that the sequences of the ITS and D1/D2 regions were 100% similar to those of various S. commune strains, such as IFM 46097. The diagnosis of allergic bronchopulmonary mycosis (ABPM) due to co-infection with A. fumigatus and S. commune was made.\nThe susceptibility of the isolated A. fumigatus and S. commune strains to antifungal drugs (minimum inhibitory concentration; MIC) was as follows: amphotericin B (1 and 0.5 μg/mL), 5-fluorocytosine (64 and 0.25 μg/mL), fluconazole (>64 and 4 μg/mL), itraconazole (0.12 and 0.25 μg/mL), voriconazole (0.5 and 0.12 μg/mL), and micofungin (0.03 and >16 μg/mL), respectively.\nThe administration of oral itraconazole and prednisolone, improved the symptoms in this patient.
A 25-year-old female with a two-year history of erythema, papules, nodules, and scales on her sole of left foot was presented to our outpatient center. She has no history of autoimmue disease and untreated with immunosuppressive therapy. Considering her pregnancy, she was not given treatments for 1 year. The left foot skin lesion on the medial and lateral margins and on the fourth toe dorsum became enlarged with evident pain after more than 1 year (Fig. ). Approximately 1 month before visiting our department, she received treatment ineffectively in a local clinic, and the diagnosis was unclear.\nSamples were obtained by the scraping of lesion and for light microscopy. Hyphae were observed by microscopic examination (Fig. ).\nWe carried out a skin tissue biopsy, which showed multiple granulomatous nodules (Fig. ). The Ziehl–Neelsen stain was negative. Periodic acid–Schiff (PAS) and Grocott methenamine silver (GMS) staining were carried out two times. Results were also negative. Biopsy specimens were also inoculated onto two kinds of media: Sabouraud’s dextrose agar (SDA), where one of which contained chloramphenicol and cycloheximide, and the other one contained chloramphenicol only. After being cultured on SDA at 27 °C for 7 days, spreading-woolly-white colonies grew on the inoculation sites of media containing chloramphenicol only and there,s no other colonies grew (Fig. ). The colonies produced an unpleasant smell like biogas. No colony was observed on the media with chloramphenicol and cycloheximide. Clamp connections, spicules, tear-like secretions, and medusa-like isomers were observed on the slide culture at 27 °C after 3 days (Fig. ). Urease activity tests were also performed. Trichophyton rubrum standard strain and the isolated strain were cultured on urease media at 27 °C for 7 days. The T. rubrum standard strain was negative, whereas the isolated strain turned red (Fig. ).\nSequencing of large subunit rDNA was performed by using the E.Z.N.A.™ Fungal DNA Mini Kit (Omega Biotek, USA). We utilized set primers for the region of internal transcribed spacer (ITS) and performed PCR. The PCR primers were ITS1: 5′-TCCGTAGGTGAACCTGCGG-3′ and ITS4: 5′-TCCTCCGCTTATTGATATGC-3′. The PCR-amplified DNA was matched with that of S. commune (Nos. KP 326677.1 and KP 004975.1) with a homology of 100%. After identification, the sequence was submitted to the GenBank (MF 495704).\nPathological finding and mycological examination indicated a cutaneous granuloma caused by S. commune. Oral itraconazole (100 mg) was applied twice a day. The rashes on the left foot and the pain regressed after 1 month of treatment (Fig. ). Follow-up is currently under way.