Brandt M E, Warnock D W
Mycotic Diseases Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
J Chemother. 2003 Nov;15 Suppl 2:36-47. doi: 10.1179/joc.2003.15.Supplement-2.36.
The dematiaceous (brown-pigmented) fungi are a large and heterogenous group of moulds that cause a wide range of diseases including phaeohyphomycosis, chromoblastomycosis, and eumycotic mycetoma. Among the more important human pathogens are Alternaria species, Bipolaris species, Cladophialophora bantiana, Curvularia species, Exophiala species, Fonsecaea pedrosoi, Madurella species, Phialophora species, Scedosporium prolificans, Scytalidium dimidiatum, and Wangiella dermatitidis. These organisms are widespread in the environment, being found in soil, wood, and decomposing plant debris. Cutaneous, subcutaneous, and corneal infections with dematiaceous fungi occur worldwide, but are more common in tropical and subtropical climates. Infection results from traumatic implantation. Most cases occur in immunocompetent individuals. Dematiaceous moulds are also important causes of invasive sinusitis and allergic fungal sinusitis. Infection is thought to follow inhalation. Although cerebral infection is the commonest form of systemic phaeohyphomycosis, other localized deep forms of the disease, such as arthritis, and endocarditis, have been reported. Disseminated infection is uncommon, but its incidence is increasing, particularly among immunocompromised individuals. Scedosporium prolificans is the most frequent cause. A number of dematiaceous fungi are neurotropic, including Cladophialophora bantiana, Ramichloridium mackenziei, and Wangiella dermatitidis. Although cases have occurred in immunocompromised persons, cerebral phaeohyphomycosis is most common in immunocompetent individuals with no obvious risk factors. Most forms of disease caused by dematiaceous fungi require both surgical and medical treatment. Itraconazole is currently the most effective antifungal agent for chromoblastomycosis and subcutaneous phaeohyphomycosis, while ketoconazole remains useful for mycetoma. Extensive surgical debridement combined with amphotericin B treatment is recommended for chronic invasive sinusitis. Long-term treatment with itraconazole has led to improvement or remission in some patients that had failed to respond to amphotericin B. Allergic fungal sinusitis requires surgical removal of impacted mucin combined with postoperative oral corticosteroids. Antifungal treatment is not usually of benefit, but post-operative itraconazole may reduce the need for reoperation. The clinical outcome of cerebral and other deep-seated forms of phaeohyphomycosis is dismal, with long-term survival being reported only when complete surgical resection of discrete lesions is possible. The development of new antifungal agents and combination treatment may help to improve the management of these infections.
暗色（棕色色素沉着）真菌是一大类异质性霉菌，可引起多种疾病，包括暗色丝孢霉病、着色芽生菌病和真菌性足菌肿。较为重要的人类病原体包括链格孢属菌种、双极霉属菌种、班替枝孢瓶霉、弯孢霉属菌种、外瓶霉属菌种、裴氏着色霉、马杜拉霉属菌种、瓶霉属菌种、多育赛多孢、半知帚霉和皮炎万吉拉霉。这些微生物在环境中广泛存在，见于土壤、木材和正在分解的植物残体中。暗色真菌引起的皮肤、皮下和角膜感染在全球范围内均有发生，但在热带和亚热带气候中更为常见。感染是由创伤植入所致。大多数病例发生在免疫功能正常的个体。暗色霉菌也是侵袭性鼻窦炎和变应性真菌性鼻窦炎的重要病因。感染被认为是通过吸入引起的。虽然脑部感染是系统性暗色丝孢霉病最常见的形式，但也有其他局限性深部形式的疾病报道，如关节炎和心内膜炎。播散性感染并不常见，但其发病率正在上升，尤其是在免疫功能低下的个体中。多育赛多孢是最常见的病因。一些暗色真菌具有嗜神经性，包括班替枝孢瓶霉、麦肯齐枝孢和皮炎万吉拉霉。虽然病例发生在免疫功能低下的人群中，但脑部暗色丝孢霉病在无明显危险因素的免疫功能正常个体中最为常见。由暗色真菌引起的大多数疾病形式都需要手术和药物治疗。伊曲康唑目前是治疗着色芽生菌病和皮下暗色丝孢霉病最有效的抗真菌药物，而酮康唑对足菌肿仍然有效。对于慢性侵袭性鼻窦炎，建议广泛手术清创并联合两性霉素B治疗。对两性霉素B无反应的一些患者，长期使用伊曲康唑治疗已使其病情改善或缓解。变应性真菌性鼻窦炎需要手术清除阻塞的黏液，并联合术后口服皮质类固醇。抗真菌治疗通常没有益处，但术后使用伊曲康唑可能会减少再次手术需求。脑部和其他深部暗色丝孢霉病的临床预后很差，只有在能够对离散病变进行完全手术切除时才有长期存活的报道。新型抗真菌药物的开发和联合治疗可能有助于改善这些感染的治疗。
