Cutaneous phaeohyphomycosis in a hematopoietic stem cell transplant patient caused by Alternaria rosae : First case report

A lternaria species have been reported as a rare cause of fungal infection in organ and stem cell transplant recipients, but to date, no reports have been published of infection in humans caused by A lternaria rosae . Here, we report cutaneous A . rosae infection in a 66‐year‐old farmer with a history of primary myelofibrosis who had undergone allogeneic unrelated donor hematopoietic stem cell transplantation. Forty‐nine days post transplant, he presented with a nodule on the thumb with no findings suggestive of disseminated infection. Pathology, culture, and molecular speciation showed the nodule was caused by cutaneous A . rosae . He had been on voriconazole as antifungal prophylaxis, but was found to have a subtherapeutic voriconazole level. He was switched to posaconazole based on published in vitro data showing its superior efficacy in A lternaria treatment. Susceptibility testing showed that the A .  rosae isolate was indeed susceptible to posaconazole. His cutaneous lesion remained stable, but he died from respiratory failure secondary to lobar pneumonia. At lung autopsy, A . rosae was not identified in the lungs. We believe this to be the first published report, to our knowledge, of A . rosae infection in humans.