currently anti - tnf agents are widely used for cutaneous and systemic autoimmune diseases . for dermatologists most common indications for anti - tnf use are psoriasis and psoriatic arthritis .
we describe a case of scedosporium apiospermum infection in a patient receiving long - term treatment with etanercept , a tnf- inhibitor .
s. apiospermum is a ubiquitous filamentous fungus found in soil , polluted water , and contaminated ambient air in hospital isolation rooms . in immunocompromised patients ,
increasing reports of s. apiospermum infection in the past few years suggests that s. apiospermum is an emergent opportunistic pathogen .
infectious diseases including tuberculosis , atypical mycobacteria , histoplasmosis , coccidioidomycosis , and various opportunistic infections in patients receiving tnf - a inhibitors have been reported in the literature and postmarketing surveillance .
a pubmed search resulted in one report of scedosporium infection as a complication of infliximab therapy for ankylosing spondylitis . to the best of our knowledge ,
this is the first reported case of s. apiospermum infection in a patient receiving etanercept .
neither he had active psoriasis lesions , but he had pitting and ridging on nails .
after extensive workup , we narrowed our differential diagnosis to ankylosing spondylitis and psoriatic arthritis .
he was started on methotrexate because of continued neck and lower back pain with morning stiffness . in 2004
, etanercept was initiated at the dose of 50 mg / week and sulfasalazine was discontinued .
he did remarkably well with etanercept in respect to back pain and morning stiffness . in 2008
as he was receiving an anti - tnf agent , we actively pursued investigation for opportunistic and rare infectious agents . a flexible endoscopic examination of the sinuses demonstrated mucopurulent ethmoid disease .
tissue specimens of the right and left nasal turbinates and nasal washes were sent for evaluation and culture .
the tissue isolates showed chronic inflammatory edematous respiratory tissue without any significant pathology in the underlying bones and gms stains showed no evidence of fungus .
however , cultures of the specimen from the sphenoid sinuses returned positive for s. apiospermum .
a mri of head and sinuses did not demonstrate any evidence for invasive rhinocerebral fungal disease .
we consulted our infectious disease colleagues and the patient was started on voriconazole 200 mg bid .
follow - up mri and ct of the brain and sinuses did not show any evidence for sinusitis or invasion of the adjacent anatomical structures .
as there was no histopathological or radiological evidence for invasive fungal infection we felt comfortable to continue etanercept .
the patient has continued to take both etanercept and methotrexate for more than 1 year with no signs of re - infection or complication .
scedosporium apiospermum has been associated with mycetoma , keratitis , endophthalmitis , osteomyelitis , and brain abscesses .
a wide range of pulmonary manifestations exists , ranging from simple colonization as seen in patients with cystic fibrosis to fungus ball formation in patients with cavitary lesions and invasive disease , simulating aspergillosis .
as the clinical presentation of scedosporium infection , including fever , cough , and dyspnea is nonspecific , diagnosis can be based on cytology , histopathology , and isolation of the fungus in culture .
culture confirmation is important as the histological appearance and clinical presentation of s. apiospermum are difficult to distinguish from that of the aspergillus species on pathological examination . in a case report of three lung transplant patients ,
mean - time from specimen collection to positive - culture identification for sputum culture was 4.5 days compared to 9.5 days with bronchoalveolar lavage culture . in our patient , positive culture was identified in 10 days .
s. apiospermum has been shown to have intrinsic resistance to many anti - fungal agents , including fluconazole and amphotericin b , the traditional antifungal of choice for disseminated hyalohyphomycoses .
much of the data on the treatment of s. apiospermum pertains to the use of voriconazole .
a retrospective review of 107 patients treated for scedosporium infection with voriconazole showed 57% of patients achieved a successful response after a median of 103 days of therapy . in vitro studies
have demonstrated that voriconazole is more active against s. apiospermum than either itraconazole or amphotericin b. the optimal choice and duration of therapy remain unknown .
surgical debridement or drainage for limited disease in combination with antifungal therapy , as was done successfully with our patient , is recommended now .
 patients on anti - tnf therapy are at increased risk for rare opportunistic infections . here we are reporting a case of scedosporium apiospermum infection in a patient treated with anti - tnf for 5 years . 
 patients on anti - tnf need close follow - up and clinicians should be suspicious for atypical infections in these immunocompromised hosts . 
Introduction
Case Report
Discussion