Med Mycol J 2017 ;58(2):E71-E77

Department of Dermatology, Kitasato University Kitasato Institute Hospital.

Understanding deep cutaneous fungal infection requires not only reading many case reports and checking the typical clinical images of skin lesions, but also managing the patients properly to prevent misdiagnosis. Herein, I review my recent experiences with eight typical cases of deep cutaneous infections (including protothecosis and nocardiosis) in Japan. It is very important to do the four management processes; namely, KOH direct microscopic examination, skin biopsy, fungal culture, and microscopic examination of the histopathological specimen of PAS and Grocott staining. Read More

Arkh Patol 2017;79(1):52-55

M.F. Vladimirsky Moscow Regional Research Clinical Institute, Moscow, Russia.

The paper describes a case of a rare opportunistic infection, such as skin lesion caused by achlorophyllic unicellular algae of the genus Prototheca. It provides a detailed pathologic description of the foci of cutaneous protothecosis, such as pandermal inflammatory infiltrate, granulomas, pseudoepitheliomatous hyperplasia, and intraepidermal abscesses. Criteria for pathogen detection in histological sections are given. Read More

Pediatr Infect Dis J 2017 Jul;36(7):687-689

From the *Department of Laboratory Medicine, †Department of Pediatrics, and ‡Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.

Human protothecosis is mainly a cutaneous infection caused by the Prototheca species. Prototheca wickerhamii is an established pathogen of eosinophilic meningoencephalitis in dogs, but no eosinophilic pleocytosis of the cerebrospinal fluid has been reported in human cases of meningitis. Herein, we report a case of chronic protothecosis manifesting eosinophilic meningoencephalitis in an immunocompetent boy. Read More

Clin Exp Dermatol 2017 Jan;42(1):72-74

National Skin Centre, Singapore, Singapore.

Cutaneous protothecosis is caused by the achlorophyllic algae Prototheca, typically presenting as a localized plaque in immunocompetent individuals. We report a patient with bilateral erythematous plaques and pustules on her forearms, which had initially been treated with steroids for presumed eczema. Histology showed spherical spore-like bodies with internal morula-like septation, which were positive for periodic-acid-Schiff (PAS) staining, consistent with cutaneous protothecosis. Read More

Mycopathologia 2017 Jun 26;182(5-6):603-608. Epub 2016 Dec 26.

General Diagnostic Department, Istituto Zooprofilattico Sperimentale del Lazio e della Toscana "M. Aleandri", Via Appia Nuova 1411, 00178, Rome, Italy.

Protothecosis is a disease caused by saprophyte aerobic unicellular algae belonging to the genus Prototheca. In dogs, it mainly occurs as a disseminated form, with initial clinical manifestations often referable to the gastrointestinal tract, followed by typical ocular and neurological signs. So far, Prototheca zopfii genotype 2 infection has been reported in severe forms of disseminated protothecosis, while in dogs has never been associated with cutaneous forms. Read More

Int J Dermatol 2016 Dec 23;55(12):1373-1377. Epub 2015 Dec 23.

Department of Dermatology, Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea.

Med Mycol Case Rep 2016 Jun 3;12:21-3. Epub 2016 Aug 3.

Westmead Hospital, Sydney 2145, Australia.

Protothecosis is a rare algal infection, affecting primarily immunocompromised hosts. Optimal management is unclear: in-vitro antimicrobial breakpoints are not established and therapeutic decisions are primarily based on case reports. We present a case of cutaneous Prototheca wickerhamii infection in an immunosuppressed 63 year old male, successfully treated with liposomal amphotericin and prolonged itraconazole. Read More

Ann Dermatol 2016 Apr 31;28(2):273-4. Epub 2016 Mar 31.

Department of Dermatology, Ewha Womans University School of Medicine, Seoul, Korea.

Transpl Infect Dis 2015 Aug 7;17(4):599-604. Epub 2015 Jul 7.

Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut, USA.

Prototheca wickerhamii is an alga that rarely causes human disease but has been reported increasingly among immunocompromised individuals. We report a fatal case of P. wickerhamii in a renal transplant recipient who presented with a cutaneous lesion that led to disseminated disease despite treatment with voriconazole. Read More

J Comp Pathol 2015 May 23;152(4):287-90. Epub 2015 Mar 23.

Institute of Pathology, Faculty of Veterinary Medicine, University of Leipzig, An den Tierkliniken 33, Leipzig, Germany. Electronic address:

Few published cases of feline protothecosis exist; all of these were restricted to the skin and speciation of the causative organism revealed an infection with Prototheca wickerhamii in each case. This report describes Prototheca zopfii genotype 2-induced inflammation of the nasal skin and cutaneous mucosa of the right nostril in a 14-year-old neutered female domestic shorthair cat. Microscopical examination revealed marked pyogranulomatous inflammation with numerous intralesional algae. Read More

Mycopathologia 2015 Feb 9;179(1-2):163-6. Epub 2014 Sep 9.

Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, 200040, China,

We report a case of cutaneous protothecosis due to Prototheca wickerhamii in an immunocompetent man presented with a specific eczema-like lesions. Dermatological examination revealed erythematous plaques, dark red papules with some coalescence, and a few superficial ulcerations, covered with less scales on his right side chest and neck. Fungal culture, histopathological examination and molecular identification confirmed the organism. Read More

Am J Dermatopathol 2014 Jul;36(7):531-53; quiz 554-6

*Consultant Histopathologist, Dermatopathology and Lymphoid Area, Department of Cellular Pathology, Hospital El Bierzo, Ponferrada, Spain; †Dermatologist, Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, INER/CIENI, Hospital Angeles Lomas, Centro Medico ABC, Huixquilucan, México; and ‡Dermatologist and Mycologist, Hospital General Dr. Manuel Gea Gonzalez, Mexico City, México.

Cutaneous fungal infections used to be rare in most developed countries. However, they have become more common due to immunosuppression and globalization. In this report, we summarize the histopathologic findings of the main cutaneous fungal infections that are commonly seen in daily practice, including eumycetoma, sporotrichosis, histoplasmosis, cryptococcosis, coccidioidomycosis, aspergillosis, zygomycosis, phaeohyphomycosis, alternariosis, blastomycosis, paracoccidioidomycosis, lobomycosis, and chromoblastomycosis. Read More

Med Mycol J 2014 ;55(1):E29-32

Department of Pathobiology, Nihon University School of Veterinary Medicine.

Protothecosis is a rare infection caused by pathogenic algae of the genus Prototheca. Prototheca wickerhamii causes cutaneous/subcutaneous opportunistic infections in humans and small animals. The diagnosis of protothecosis is based on histopathological examination of this organism, which can be confused with other fungi and inflammatory cells in infected tissues. Read More

Australas J Dermatol 2015 Aug 4;56(3):e71-3. Epub 2014 Mar 4.

National Skin Centre, Singapore.

Protothecosis is an uncommon condition resulting from infection by achlorophyllous algae of the Prototheca species. Immunocompromised individuals are generally most susceptible to protothecal infection and tend to develop severe and disseminated disease. However, the association between protothecosis and HIV-induced immunosuppression is not clear, with only a handful of cases having been described to date. Read More

Med Mycol Case Rep 2013 Jun 20;2:132-3. Epub 2013 Jun 20.

Austin Centre for Infection Research, Austin Health, Heidelberg, VIC 3084, Australia.

Prototheca wickerhamii has been predominantly recognised as a pathogen in immunocompromised hosts with deficits in innate or cellular immunity. The role of specific immunoglobulin against Prototheca in host immunity is uncertain. We describe a case of persistent cutaneous protothecosis in a patient with hypogammaglobulinemia most likely due to common variable immunodeficiency, with clinical response to voriconazole. Read More

Korean J Pathol 2013 Dec 24;47(6):575-8. Epub 2013 Dec 24.

Department of Pathology, Kwandong University College of Medicine, Gangneung, Korea.

The Prototheca species is achlorophyllic algae and rarely causes human infection. Human protothecosis presents clinically as a cutaneous infection, olecranon bursitis, and disseminated systemic disease. We report a case of human cutaneous protothecosis involving the left wrist. Read More

J Mycol Med 2014 Mar 31;24(1):34-43. Epub 2013 Dec 31.

Microbiology Department, University of Agricultural Sciences and Veterinary Medicine, Faculty of Veterinary Medicine, 3-5, Mănăştur Street, 400372, Cluj-Napoca, Romania.

Background: To date there is no defined pharmacologic treatment protocol available against cutaneous protothecosis, which is difficult to combat using conventional drugs.

Objectives: Our experiment aimed to comparatively investigate the effect of two essential oils (Mentha piperita and Saturenja hortensis) against cutaneous protothecosis experimentally induced by Prototheca zopfii in mice.

Materials And Methods: Immunosuppressed BALB/c female mice, were divided into six experimental groups, infected with P. Read More

An Bras Dermatol 2013 Nov-Dec;88(6 Suppl 1):183-5

Federal University of the State of Rio de Janeiro.

Cutaneous protothecosis is a rare infection caused by achlorophyllic algae of the genus Prototheca. The lesions usually occur on exposed areas, related with trauma, in immunocompromised patients. The most common clinical presentation is a vesicobullous and ulcerative lesion with pustules and scabs, simulating bacterial, fungal or herpetic infections or eczema. Read More

Pediatr Infect Dis J 2013 Dec;32(12):e476-7

From the *Department of Microbiology, Medicine Faculty, Autonomous University of San Luis Potosi, San Luis Potosí, Mexico; and †Department of Pathology, Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosí, Mexico.

Protothecosis is a rare human infection. There are 3 clinical forms: cutaneous, olecranon bursitis and systemic. Here we present the first case of disseminated protothecosis in Mexico in an immunocompetent girl whose lesions were mostly dermatologic. Read More

Int J Dermatol 2012 Nov;51(11):1340-2

Division of Dermatology, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand.

Clin Dermatol 2012 Jul-Aug;30(4):432-6

Instituto Dermatológico de Jalisco Dr. José Barba Rubio, Zapopan, Avenida Federalismo #3102, Colonia Atemajac, Zapopan, Jalisco, Mexico.

Protothecosis is a rare infection caused by achlorophyllic algae that are members of the genus Prototheca. They are ubiquitous in nature in organic material. The clinical manifestations can be acute or chronic and local or disseminated. Read More

Int J Dermatol 2012 Mar;51(3):328-31

Department of Dermatology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.

Hippokratia 2012 Jan;16(1):95

Department of Skin and Venereal Diseases, Medical School, University of Ioannina, Ioannina, Greece.

Dermatol Online J 2011 Sep 15;17(9). Epub 2011 Sep 15.

Department of Dermatology and Allergology, Juntendo University Nerima Hospital.

A 76-year-old woman farmer with a 20-year history of oral steroid treatment for polyarteritis nodosa, noted a rash consisting of numerous small papules on the dorsum of her right hand in February 2007. The rash worsened over time, and in April 2008 red papules and pustules as big as grains of rice fused to form plaques extending up her arm from the dorsum of the right hand to the extensor surface of the forearm. The plaques were accompanied by erosions, ulcers, and crusts. Read More

Mycopathologia 2012 Mar 2;173(2-3):163-71. Epub 2011 Oct 2.

The Center for Medical Mycology, Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, People's Republic of China.

Protothecosis is an opportunistic infection caused by Prototheca, usually called as saprophytes, and is frequently found in natural and living surroundings with low virulence, but may cause chronic infection in immunocompromised individuals. We report a case of cutaneous protothecosis with zopfii var. portoricensis infection in a 66-year-old diabetic woman following hand surgery on middle right finger. Read More

Arch Pathol Lab Med 2011 Jul;135(7):941-4

Department of Pathology and Laboratory Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA.

Prototheca species are an achlorophyllic algae that cause infections primarily in immunocompromised individuals. At least one-half of infectious cases are cutaneous. Because protothecosis is seldom suspected clinically, patients may be subjected to various treatment modalities for extended periods without satisfactory results. Read More

Ann Dermatol Venereol 2010 Nov;137 Suppl 3:S89-96

Clinique Dermatologique, Faculté de Médecine, Université de Strasbourg, Hôpitaux Universitaires, 1 place de l'Hôpital 67091 Strasbourg cedex, France.

Through its anatomical, topographical, and functional distinctiveness, more than all other parts of the body, the hand is the interface between humans and their environment. All types of stimulus produce cutaneous signs in the hands, notably cold, light, pressure, contact, etc. Exposure to light makes it the region where photodermatosis is expressed, but also a particular site for cutaneous carcinogenesis. Read More

Med Mycol 2010 Jun;48(4):643-6

Division of Dermatology, Tottori University, Yonago, Japan.

We report a case of human protothecosis in an immunocompromised host which was caused by Prototheca wickerhamii and was successfully treated with thermal adjunct therapy combined with systemic itraconazole therapy. A 78-year-old man taking 30 mg prednisolone daily had a 1-week history of erythematous plaques on the dorsal aspect of his right hand and forearm after sustaining a small traumatic injury. Histopathology of the lesions revealed granulomatous inflammatory changes with numerous microorganisms that had multiple septations in their cytoplasm. Read More

J Cutan Med Surg 2009 Sep-Oct;13(5):273-5

Departments of Dermatology and Skin Science and Pathology and Laboratory Medicine, CIHT Skin Research Training Centre, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC.

Background: Prototheca species are ubiquitous achlorophyllic algae that can, in rare instances, manifest as cutaneous infection in humans at sites of traumatic inoculation into the skin.

Objectives: We report a 77-year-old man who developed cutaneous protothecosis at the site of an iatrogenic tape-stripping type injury. The diagnosis was confirmed by histologic examination and tissue culture. Read More

Clin Orthop Relat Res 2008 Dec 13;466(12):3143-6. Epub 2008 Sep 13.

Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, #50, ILwon-Dong, Kangnam-Gu, Seoul, 135-710, South Korea.

Protothecosis is a rare infection caused by achlorophyllic algae called Prototheca. Approximately 117 cases have been described in the literature world wide, the majority caused by the species P. wickerhamii. Read More

Vet Pathol 2008 May;45(3):352-4

Hospital Veterinário, CSTR, Universidade Federal de Campina Grande, Campus de Patos, Patos, Paraíba, 58700-000, Brazil.

A case of protothecosis is reported in an adult goat with inspiratory dyspnea and stertor. Dermatitis with prominent ulcerated nodules up to 3 cm in diameter was observed in the muzzle at the mucocutaneous junctions of nasal and lip skin, and in the border of the pinna. Histologic lesions were necrotizing pyogranulomatous dermatitis and rhinitis with myriads of walled sporangia, characteristic of Prototheca wickerhamii. Read More

Cutis 2007 Aug;80(2):129-31

University of South Florida College of Medicine, Tampa, USA.

Protothecosis is a rare cause of systemic and/or cutaneous infection. Because approximately 100 cases of human infection with Prototheca wickerhamii have been reported, little is known about the pathogenesis of this infection. Cases include both immunocompetent and immunocompromised patients. Read More

Rev Soc Bras Med Trop 2007 Jul-Aug;40(4):466-8

Centro de Anatomia Patológica, Hospital Universitário de Brasília, Brasília, DF.

A case of cutaneous protothecosis was reported in a 78-year-old man that was in treatment for pemphigus foliaceus and phaeohyphomycosis. He presented erythematous lesions which were infiltrated into his right leg. The diagnosis was made histopathologically and confirmed by culture, and the patient was successfully treated with itraconazole. Read More

Clin Microbiol Rev 2007 Apr;20(2):230-42

Department of Hygiene, Microbiology and Social Medicine, Innsbruck Medical University, Fritz Pregl Str. 3/III, 6020 Innsbruck, Tyrol, Austria.

Human protothecosis is a rare infection caused by members of the genus Prototheca. Prototheca species are generally considered to be achlorophyllic algae and are ubiquitous in nature. The occurrence of protothecosis can be local or disseminated and acute or chronic, with the latter being more common. Read More

Int J Dermatol 2006 Feb;45(2):124-6

Division of Dermatology, Department of Medicine, Santa Casa Medical School, São Paulo, Brazil.

The present report describes a case of cutaneous protothecosis caused by Prototheca wickerhamii in a nonimmunocompromised Brazilian female. Dermatological examination revealed a 15-cm diffusely infiltrated eczema-like plaque recovered with many pustule-like lesions on the right forearm. We emphasize the mycological and pathological aspects of this infection that can lead to misdiagnosis. Read More

Med Mycol 2004 Apr;42(2):95-106

Mycology Service, Evandro Chagas Institute of Clinical Research, IPEC/FIOCRUZ, Rio de Janeiro, Brazil.

Protothecosis is an infection caused by achlorophyllic algae of the genus Prototheca which rarely affects humans. Some 100 cases have been described in the medical literature, the majority caused by the species P. wickerhamii. Read More

Int J Dermatol 2002 May;41(5):304-6

Department of Dermatology, St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.

Br J Dermatol 2002 Apr;146(4):713-5

Br J Dermatol 2002 Apr;146(4):688-93

Department of Dermatology, National Cheng-Kung University Hospital, 138 Sheng-Li Road, Tainan 704, Taiwan.

Prototheca, a genus of achlorophyllic algae, is a rare cause of opportunistic infection in humans. About 80 human cases, mostly cutaneous infection caused by P. wickerhamii, have been reported world-wide. Read More

Int J Hyg Environ Health 2002 Feb;204(5-6):297-302

Institute of Animal Hygiene and Veterinary Public Health, University of Leipzig, Leipzig, Germany.

Prototheca spp. are ubiquitous achlorophyllous algae that produce disease in humans and animals. In the past years infections with Prototheca have obtained increasing importance in human medicine. Read More

Rev Inst Med Trop Sao Paulo 2001 Sep-Oct;43(5):287-90

Hospital Universitário Professor Edgar Santos, Federal University of Bahia, School of Medicine, Escola Bahiana de Medicina e Saúde Pública, BA, Brazil.

The present report describes a case of cutaneous protothecosis caused by Prototheca wickerhamii in a non-immunocompromised female from the state of Bahia, Brazil. This is the second case described in Brazil. Dermatological examination revealed diffusely infiltrated erythematous plaques on the flexor aspect of the right arm and forearm. Read More

BMC Microbiol 2001 24;1:21. Epub 2001 Sep 24.

Department of Dermatology, Brooke Army Medical Center, Ft Sam, Houston, Texas 78234, USA.

Background: Fluorescence of many fungi is noted when H&E stained sections are examined under a fluorescent microscope. In theory, this phenomenon could aid in the diagnosis of cutaneous and disseminated fungal infections without the delay associated with special stains. Seventy-six cases of superficial and deep fungal infections and 3 cases of protothecosis were studied to determine the clinical usefulness of this technique. Read More

Nihon Ishinkin Gakkai Zasshi 2001 ;42(3):143-7

Department of Dermatology, Showa University, Fujigaoka Hospital, Yokohama, Japan.

Cutaneous protothecosis developed in a 63-year-old Japanese female. The patient had a long history of steroid use for bronchial asthma. A tender, swollen, erythematous plaque with white papules covered the dorsal aspect of the patients right hand. Read More

Int J Antimicrob Agents 2000 Aug;15(3):235-7

School of Public Health, University of Trnava, St Elizabeth Cancer Institute, Bratislava, Slovak Republic.

One hundred and eight cases of human protothecosis occurring over 25 years are reviewed. The most common species isolated was Prototheca wickerhamii, The algae have been isolated from a large number of sites but seem to have low virulence. In the majority of systemic infections there have been few symptoms. Read More

Cutis 1999 Mar;63(3):185-8

University of Maryland Department of Dermatology, Baltimore 21201, USA.

Protothecosis is an infection caused by achloric algae of the genus Prototheca. These organisms have been isolated from water, sewage, soil, and the slime flux of trees, and are a known cause of disease in other mammals. Infection in humans occurs after traumatic inoculation, producing localized olecranon bursal or, rarely, systemic disease. Read More

Clin Infect Dis 1997 Nov;25(5):1265-6

Department of Dermatology, New York University Medical Center, New York 10016, USA.

South Med J 1997 Aug;90(8):831-2

Department of Dermatology, University of Alabama at Birmingham, USA.

We report a case of protothecosis that occurred in the skin over the left tibial region of a 25-year-old man with the acquired immunodeficiency syndrome (AIDS). The lesion was noticed a few months after he swam in a lake in south Alabama. Biopsy and culture revealed Prototheca wickerhamii. Read More

J Comp Pathol 1997 Jul;117(1):83-9

Departamento de Anatomía y Patológica Comparadas, Facultad de Veterinaria, Córdoba, Spain.

In this immunohistochemical study, the distribution of the cellular inflammatory infiltrate associated with cutaneous canine protothecosis (Prototheca wickerhamii) was evaluated by consecutive biopsies taken before, during and after treatment. Antibodies specific to canine immunoglobulins (IgG, IgM, IgA), human CD3 antigen (pan T-lymphocyte marker) and human myeloid/ histiocyte antigen (macrophage/neutrophil marker) were used. Before treatment, cellular infiltrate was very scanty in the inflamed areas, but it increased during the treatment, whereas the number of protothecal organisms decreased. Read More

Vet Rec 1997 Jun;140(25):651-3

Department of Veterinary Clinical Pathology, Faculty of Veterinary Medicine, University of Córdoba, Spain.

A dog was infected systemically with Prototheca wickerhamii but showed only cutaneous protothecosis. The lesions appeared progressively and consisted of non-pruritic scrotal swelling and ulceration, cutaneous nodules, crusty ulcerative lesions over the trunk and serous rhinitis. The diagnosis was based on skin biopsy findings and specific culture. Read More

Br J Dermatol 1996 Nov;135(5):803-6

Department of Dermatology, Kosin Medical College, Pusan, South Korea.

We report a case of cutaneous protothecosis treated successfully with oral fluconazole. Fluconazole appears to be an effective alternative to conventional drugs for the treatment of cutaneous protothecosis. Cutaneous protothecosis is an uncommon infection due to achlorophyllic, saprophytic, algae-like unicellular organisms of the genus Prototheca that occurs mainly in immunocompromised patients. Read More