Cutaneous Protothecosis Clinical Presentation

  • Author: Sarah K Taylor, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jul 15, 2010
 

History

The classic history is that of trauma (eg, abrasion, cut) to the skin and subsequent exposure to contaminated water. In severely immunocompromised individuals, cutaneous lesions can be widespread and the algae can be present in the blood.

Patients typically present with an isolated plaque or nodule, with or without ulceration and/or pustules. However, large eczematous plaques or ulcers have also been reported. Erythema and pain may occur.

Patients with protothecosis bursitis present with painful swelling of the elbow; mild erythema; and, occasionally, drainage.

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Physical

The skin is the most common site of infection, followed by the periarticular bursae (typically causing olecranon bursitis).

Patients typically have an ill-defined plaque or nodule that may have a verrucous surface (see the image below). Large eczematous plaques; pustular lesions; and atrophic, herpetiform, hypopigmented, and cutaneous ulceration have also been reported. Bullous lesions may occur with subsequent rupture, drainage, and crusting. Lesions with the appearance of apple jelly have been reported.

This subtle lesion of cutaneous protothecosis on tThis subtle lesion of cutaneous protothecosis on the shoulder shows an ill-defined, slightly erythematous, thin plaque.

The extremities are the most common sites of involvement.

In patients who are immunocompetent, the lesions may be more subtle, with papules or plaques with mild erythema that have been stable for long periods.

Patients with olecranon bursitis have swelling; mild erythema; and, occasionally, drainage in the vicinity of the elbow.

In cases of meningeal involvement, patients may have meningeal signs of headache, nuchal rigidity, and photophobia.

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Causes

Infection is usually caused by Prototheca wickerhamii. Less commonly, infection occurs with Prototheca 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[5] ; autoimmune disease; graft versus host disease; as a result of chemotherapy or radiation therapy,[6]AIDS,[7, 8]diabetes mellitus, chronic renal failure, or Cushing disease).

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Contributor Information and Disclosures
Author

Sarah K Taylor, MD  Staff Physician, Kimbrough Dermatology, Ft George G Meade

Disclosure: Nothing to disclose.

Coauthor(s)

Jon H Meyerle, MD  Assistant Professor, Department of Dermatology, Johns Hopkins University School of Medicine; Chief, Immunodermatology, Dermatology Laboratory Director, Department of Dermatology, Walter Reed Army Medical Center and National Naval Medical Center

Jon H Meyerle, MD is a member of the following medical societies: American Academy of Dermatology and Sigma Xi

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.

Specialty Editor Board

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.

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Christen M Mowad, MD  Associate Professor, Department of Dermatology, Geisinger Medical Center

Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Department of Dermatology, Geisinger Medical Center

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

  1. Humphrey S, Martinka M, Lui H. Cutaneous protothecosis following a tape-stripping injury. J Cutan Med Surg. Sept-Oct 2009;13(5):273-5. [Medline]. [Full Text].

  2. Walsh SV, Johnson RA, Tahan SR. Protothecosis: an unusual cause of chronic subcutaneous and soft tissue infection. Am J Dermatopathol. Aug 1998;20(4):379-82. [Medline].

  3. Lass-Florl C, Mayr A. Human protothecosis. Clin Microbiol Rev. Apr 2007;20(2):230-42. [Medline].

  4. Lee JS, Moon GH, Lee NY, Peck KR. Case report: Protothecal tenosynovitis. Clin Orthop Relat Res. Dec 2008;466(12):3143-6. [Medline].

  5. 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. Nov 15 2004;104(10):3414-5. [Medline].

  6. Torres HA, Bodey GP, Tarrand JJ, Kontoyiannis DP. Protothecosis in patients with cancer: case series and literature review. Clin Microbiol Infect. Aug 2003;9(8):786-92. [Medline].

  7. Carey WP, Kaykova Y, Bandres JC, Sidhu GS, Brau N. Cutaneous protothecosis in a patient with AIDS and a severe functional neutrophil defect: successful therapy with amphotericin B. Clin Infect Dis. Nov 1997;25(5):1265-6. [Medline].

  8. Polk P, Sanders DY. Cutaneous protothecosis in association with the acquired immunodeficiency syndrome. South Med J. Aug 1997;90(8):831-2. [Medline].

  9. Yamada N, Yoshida Y, Ohsawa T, Takahara M, Morino S, Yamamoto O. A case of cutaneous protothecosis successfully treated with local thermal therapy as an adjunct to itraconazole therapy in an immunocompromised host. Med. Mycol. Jan 22 2010;[Medline]. [Full Text].

 
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This subtle lesion of cutaneous protothecosis on the shoulder shows an ill-defined, slightly erythematous, thin plaque.
Periodic acid-Schiff–stained sections of protothecosis reveal rounded endospores that form characteristic moruloid structures in the dermis.
Electron photomicrograph of Prototheca wickerhamii shows a central rounded endospore surrounded by a corona of molded endospores.
 
 
 
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