Cutaneous Protothecosis

Author: Sarah K Taylor, MD; Chief Editor: Dirk M Elston, MD more...

Updated: Jul 15, 2010

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Background
Pathophysiology
Epidemiology
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Background

In protothecosis, the skin is most commonly involved, resulting from primary inoculation through a wound or abrasion. The infection is usually localized to the site of inoculation; however, in immunocompromised individuals, it can become widespread.

Pathophysiology

Prototheca is an achlorophyllic mutant of the green alga Chlorella. The organism is ubiquitous in the environment, particularly in aqueous locales. Infection usually occurs as a result of inoculation into or beneath the skin with exposure to contaminated water or tree slime. Traumatic inoculation with no water exposure has also been reported.^[1]Person-to-person transmission does not occur. However, Prototheca has been cultured from under the fingernails and other cutaneous sites in healthy individuals.

While healthy individuals can become infected, the organism has low virulence. Protothecosis infections are more commonly described in patients who are immunosuppressed. Use of immunosuppressive drugs also increases the risk of protothecosis infections.^[2]Of all possible immunosuppressants, glucocorticoids, whether topically applied, taken orally, or locally injected, are the most specifically associated with the onset of protothecosis.^[3]In healthy individuals, the infection is localized and curable, but cases of disseminated disease in individuals who are severely immunocompromised can be fatal. Cases of disseminated disease have involved the blood, the peritoneum, the GI tract, the liver, and the meninges. A neutrophilic response appears to be critical in eradicating the infection; however, reports in the literature dispute this.

Frequency

United States

Protothecosis is a rare infection, with approximately 117 cases reported since the initial report in 1964. Most cases in the United States are from the Southeast, though cases from virtually all geographic regions have been reported.

International

Protothecosis is a rare infection, but it is seen worldwide, with cases reported on every continent except Antarctica.^[3]

Mortality/Morbidity

Patients who are severely immunocompromised can develop disseminated disease, which is often fatal. Note the following:

Localized infection: In immunocompetent individuals, the infection usually remains confined to the skin at the site of inoculation. Olecranon bursitis can develop from protothecosis. Rarely, tenosynovitis can occur and has been reported following injection of a sclerosing agent for varicose vein treatment.^[4]
Systemic infection: Rare cases of systemic infection occur almost exclusively in patients who are severely immunocompromised, as in patients receiving chemotherapy, or immunosuppressed patients, such as those on infliximab. Involvement of the meninges has been reported in a few cases of patients with AIDS.

Race

No racial predilection is noted.

Sex

No sexual predilection is evident.

Age

Protothecosis typically affects those older than 30 years or elderly persons, although pediatric cases have been reported.

Proceed to Clinical Presentation

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

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].
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].
Lass-Florl C, Mayr A. Human protothecosis. Clin Microbiol Rev. Apr 2007;20(2):230-42. [Medline].
Lee JS, Moon GH, Lee NY, Peck KR. Case report: Protothecal tenosynovitis. Clin Orthop Relat Res. Dec 2008;466(12):3143-6. [Medline].
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].
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].
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].
Polk P, Sanders DY. Cutaneous protothecosis in association with the acquired immunodeficiency syndrome. South Med J. Aug 1997;90(8):831-2. [Medline].
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].