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Pseudallescheria boydii is a species of fungus classified under Ascomycota. It is associated with some forms of eumycetoma, maduromycosis and pseudallescheriasis. Typically found in stagnant and polluted water, it has been implicated in the infection of immunocompromised and near-drowned pneumonia patients. It's asexual form is Scedosporium apiospermum. Pseudallescheria boydii fungal infection killed three athletes injured in the 1997 Maccabiah Games when, at the opening ceremony, a bridge collapsed into the Yarkon River. Treatment of infections with P. boydii is complicated by it's resistance to many of the standard antifungal agents normally used to treat infections by filamentous fungi.

Ecology
An ability to tolerate minimal aeration and high osmotic pressure enables P. boydii to grow on soil, polluted and stagnant water and manure. Although this fungus is commonly found in temperate climates, it is thermotolerant and can survive in tropical climates and in environments with low oxygen pressure. Growth of P. boydii can be seen in environments where nitrogen-containing compounds are common, usually due to human pollution. It's ability to use natural gas and other aromatic compounds suggest a capacity for bioremediation.

Growth and morphology
Pseudallescheria boydii is a saprotrophic fungus with broad hyphae growing up to 2–5 µm in width. Colonies change in colour from white to pale brown and develop a cottony texture with maturity. After a 2–3 week incubation period, cleistothecia may form containing asci filled with 8 fusiform, one-celled ascospores measuring 12–18 × 9–13 µm in diameter. This fungus grows on most standard media, maturing in 7 days. It's primary nutrients are xylose, arabinose, glucose, sucrose, ribitol, xylitol and L-arabinitol. It cannot assimilate maltose or lactose; however, it is able to assimilate urea, asparangine, potassium nitrate and ammonium nitrate. The optimal temperature for growth is 25 C and the fungus is generally considered to be mesophilic, although it can grow at higher temperatures (up to 37 C) as well. Asexual reproduction manifests in one of two forms: the Scedosporium type (the most common type) and the Graphium type. Scedosporium apiospermum forms greyish-white colonies with a grey-black reverse. The conidia are single-celled, pale brown and oval in form. Their size ranges from 4–9 x 6–10 mm and their development is annellidic.

Pathogenicity
Pseudallescheria boydii is an emerging opportunist. Immune response is characterized by TLR2 recognition of P. boydii derived α-glucans, while TLR4 mediates the recognition of P. boydii derived rhamnomannans. Human infection takes one of two forms: mycetoma (99% of infections), a chronic, subcutaneous disease, and pseudallescheriasis, which includes all other forms of the disease commonly presented in the CNS, lungs, joints and bone. The former can also be distinguished by the presence of sclerotia, or granules, which are typically absent in pseudallescheriasis - type infections. Infection is initiated via inhalation or traumatic implantation in the skin. Infection can lead to arthritis, otitis, endocarditis, sinusitis, and other manifestations. Masses of hyphae can form "fungus balls" in the lungs. While "fungus balls" can also form in other organs, they are commonly derived from host necrotic tissue resulting from nodular infarction and thrombosis of lung vessels following infection.

This species is second in prevalence after Aspergillus fumigatus as a fungal pathogen in cystic fibrosis lung. It causes allergic bronchopulmonary disease and chronic lung lesions that resemble aspergillosis. Infections can also occur in immunocompetent individuals, usually in the lungs and upper respiratory tract. Infections in the CNS, which are rare, present as neutrophilic meningitis or multiple brain abscesses and have a mortality rate of up to 75%. Infections have also been observed in animals. P. boydii has been found to be a causal agent of keratitis, abdominal eumycotic mycetoma and disseminated infections in dogs and horses. Transient colonization is more likely than disease. However, invasive pseudoallescheriasis can be found in patients with prolonged neutropenia, high-dose corticosteroid therapy and allogeneic bone marrow transplantation. P. boydii has also been implicated in near-drowning pneumonia, being the most common fungal cause of this disease with a high fatality rate. It manifests anywhere between a few weeks to several months after exposure. Reported cases of near-drowning P. boydii infections included dissemination of the organism to the CNS. This species is also known as a non-invasive colonist of the external ear and airways of patients with poor lung or sinus clearance. It has also been implicated in infection of joints following traumatic injury, and these infections can progress to osteomyelitis. Infections of the skin and cornea have also been reported. Typical host-related risk factors for infection include lymphopenia, steroid treatment, serum albumin levels of <3 mg/dL and neutropenia.

Diagnosis
Detection and diagnosis of S. apiospermum is possible through isolation of the fungus in culture or through cytology and histopathology in the tissues of diseased individuals. In mycetoma-type infections, a confluence of symptoms is necessary for diagnosis, including tumefaction, draining sinuses and extrusion of grains. Furthermore, P. boydii grains and hyphae should be cultured and observed microscopically after staining with H&E, PAS stain, Tissue Gram or Grogott-Gomori methenamine silver. A radiological diagnosis may be helpful in elucidating the extent of the disease in terms of bone and soft tissue involvement. Scedosporium-caused eumycetomas have been found to have thick-walled cavities and grains appearing as hyperreflective echoes on scans, while actinomycetomas show fine echoes at the bottom of cavities.

Direct detection is possible in samples histochemically stained in 20% KOH followed by fluorescence microscopy with antibody. The characteristic shape, texture and colour of tissues can help identify S. apiospermum grains, which are often surrounded by an eosinophilic zone. Histopathologically, hyalohyphomycotic fungi like Scedosporium spp., Aspergillus spp., Fusarium spp. and Petriella spp. are similar in that they show septation of hyphae at regular intervals, have dichotomous branching and invade blood vessels. However, Scedosporium presents more irregular branching, sometimes with terminal or intercalary chlamydospores. In serum, Scedosporium infections can be detected by counterimmunoelectrophoresis. Molecular diagnostics appear to be promising in complementing current conventional diagnostic methods.

Culture detection is accomplished by rinsing "grains" in 70% ethanol and sterile saline solution to avoid bacterial contamination prior to inoculation on growth medium. Selection of Scedosporium growth can be achieved on Leonian's agar supplemented with 10 g/mL benomyl, or on media containing cycloheximide or amphotericin B. Optimal incubation is at a temperature of 25–35 C.

Treatment
Pseudallescheria boydii is resistant to amphotericin B and nearly all other antifungal drugs. Consequently, there is currently no consistently effective antifungal therapy for this agent. Miconazole has shown the best in vivo activity; however, itraconazole, fluconazole, ketoconazole and voriconazole have also been used in treatment, albeit with less success. In an in vitro environment, terbinafine has been found to work in synergy with azoles against P. boydii. Echinocandins, such as caspofungin and sordarins, have shown promise in in vitro assays. CMT-3, a chemically modified tetracycline, has also shown to be active in vitro against P. boydii.

Epidemiology
In the United States, P. boydii is the most common causal agent of mycetoma, and tends to be more common in men than in women, particularly in the 20-45 year old age group. In the United States, the incidence of infection by S. apiospermum between 1993 and 1998 was 0.82; this figure increased to 1.33 by 2005. Pseudallescheria boydii infection was implicated in the deaths of three athletes injured during the opening ceremony of the 1997 Maccabiah Games when the Maccabiah bridge collapsed in the Yarkon River.