Arachnoid Membrane Suturing for Prevention of Subdural Fluid Collection in Extracranial-intracranial Bypass Surgery

OBJECTIVE: Water-tight closure of the dura in extracranial-intracranial (EC-IC) bypass is impossible because the superficial temporal artery (STA) must run through the dural defect. Consequently, subdural hygroma and subcutaneous cerebrospinal fluid (CSF) collection frequently occur postoperatively. To reduce these complications, we prospectively performed suturing of the arachnoid membrane after STA-middle cerebral artery (STA-MCA) and evaluated the clinical usefulness. MATERIALS AND METHODS: Between Mar. 2005 and Oct. 2010, extracranial-intracranial arterial bypass (EIAB) with/without encephalo-myo-synangiosis was performed in 88 cases (male : female = 53 : 35). As a control group, 51 patients (57 sides) underwent conventional bypass surgery without closure of the arachnoid membrane. Postoperative computed tomography (CT) scan was performed twice in three days and seven days later, respectively, for evaluation of the presence of subdural fluid collection and other mass lesions. RESULTS: The surgical result was excellent, with no newly developing ischemic event until recent follow-up. The additional time needed for arachnoid suture was five to ten minutes, when three to eight sutures were required. Post-operative subdural fluid collection was not seen on follow-up computed tomography scans in all patients. CONCLUSION: Arachnoid suturing is simple, safe, and effective for prevention of subdural fluid collection in EC-IC bypass surgery, especially the vulnerable ischemic hemisphere.

Pterional-subolfactory Approach for Treatment of High Positioned Anterior Communicating Artery Aneurysms

OBJECTIVE: The purpose of this study is to compare the surgical outcomes of pterional-subolfactory approach for the high positioned anterior communicating artery (ACoA) aneurysm with the conventional pterional approach. METHODS: Between February 2005 and December 2012, 463 ACoA aneurysms were surgically treated in our institution. Forty eight high positioned ACoA aneurysms were treated with pterional-subolfactory or conventional pterional approach. High positioned ACoA aneurysms were defined as aneurysms located higher than 10 mm above the anterior clinoid process. Pterional-subolfactory approach is a procedure including dissection of olfactory tract and resection of the gyrus rectus inferior and medial to the olfactory tract. Thirty-four of the 48 cases were treated with pterional-subolfactory approach and 14 were treated conventionally. RESULTS: There were 2 postoperative cerebral infarction with the conventional pterional approach, but none with the pterional-subolfactory approach group (p = 0.026). Postoperative digital subtraction angiography revealed significant remnant aneurysm in the conventional pterional approach group. All patients with unruptured aneurysms had good clinical outcomes with Glasgow outcome score of 5. Among ruptured ACoA aneurysm patients, 2 patients with conventional pterional approach had postoperative cerebral infarctions but permanent neurologic deficit was found in only 1 patient. Three patients treated with the pterional-subolfactory approach, who had preoperative ruptured aneurysms had poor clinical outcomes. The mean operation time for the conventional pterional approach was 58 minutes longer than for the pterional-subolfactory approach (p = 0.001). CONCLUSION: We concluded that pterional-subolfactory approach is highly preferable for cases of high positioned ACoA aneurysm, giving a wide and effective operation view.

Pterional-subolfactory Approach for Treatment of High Positioned Anterior Communicating Artery Aneurysms

OBJECTIVE: The purpose of this study is to compare the surgical outcomes of pterional-subolfactory approach for the high positioned anterior communicating artery (ACoA) aneurysm with the conventional pterional approach. METHODS: Between February 2005 and December 2012, 463 ACoA aneurysms were surgically treated in our institution. Forty eight high positioned ACoA aneurysms were treated with pterional-subolfactory or conventional pterional approach. High positioned ACoA aneurysms were defined as aneurysms located higher than 10 mm above the anterior clinoid process. Pterional-subolfactory approach is a procedure including dissection of olfactory tract and resection of the gyrus rectus inferior and medial to the olfactory tract. Thirty-four of the 48 cases were treated with pterional-subolfactory approach and 14 were treated conventionally. RESULTS: There were 2 postoperative cerebral infarction with the conventional pterional approach, but none with the pterional-subolfactory approach group (p = 0.026). Postoperative digital subtraction angiography revealed significant remnant aneurysm in the conventional pterional approach group. All patients with unruptured aneurysms had good clinical outcomes with Glasgow outcome score of 5. Among ruptured ACoA aneurysm patients, 2 patients with conventional pterional approach had postoperative cerebral infarctions but permanent neurologic deficit was found in only 1 patient. Three patients treated with the pterional-subolfactory approach, who had preoperative ruptured aneurysms had poor clinical outcomes. The mean operation time for the conventional pterional approach was 58 minutes longer than for the pterional-subolfactory approach (p = 0.001). CONCLUSION: We concluded that pterional-subolfactory approach is highly preferable for cases of high positioned ACoA aneurysm, giving a wide and effective operation view.

Value of Indocyanine Green Videoangiography in Deciding the Completeness of Cerebrovascular Surgery

OBJECTIVE: Recently, microscope-integrated near infrared indocyanine green videoangiography (ICG-VA) has been widely used in cerebrovascular surgery because it provides real-time high resolution images. In our study, we evaluate the efficacy of intraoperative ICG-VA during cerebrovascular surgery. METHODS: Between August 2011 and April 2012, 188 patients with cerebrovascular disease were surgically treated in our institution. We used ICG-VA in that operations with half of recommended dose (0.2 to 0.3 mg/kg). Postoperative digital subtraction angiography and computed tomography angiography was used to confirm anatomical results. RESULTS: Intraoperative ICG-VA demonstrated fully occluded aneurysm sack, no neck remnant, and without vessel compromise in 119 cases (93.7%) of 127 aneurysms. Eight clipping (6.3%) of 127 operations were identified as an incomplete aneurysm occlusion or compromising vessel after ICG-VA. In 41 (97.6%) of 42 patients after carotid endarterectomy, the results were the same as that of postoperative angiography with good patency. One case (5.9%) of 17 bypass surgeries was identified as a nonfunctioning anastomosis after ICG-VA, which could be revised successfully. In the two patients of arteriovenous malformation, ICG-VA was useful for find the superficial nature of the feeding arteries and draining veins. CONCLUSION: ICG-VA is simple and provides real-time information of the patency of vessels including very small perforators within the field of the microscope and has a lower rate of adverse reactions. However, ICG-VA is not a perfect method, and so a combination of monitoring tools assures the quality of cerebrovascular surgery.

Evaluation of Probability of Survival Using Trauma and Injury Severity Score Method in Severe Neurotrauma Patients

OBJECTIVE: Despite several limitations, the Trauma Injury Severity Score (TRISS) is normally used to evaluate trauma systems. The aim of this study was to evaluate the preventable trauma death rate using the TRISS method in severe trauma patients with traumatic brain injury using our emergency department data. METHODS: The use of the TRISS formula has been suggested to consider definitively preventable death (DP); the deaths occurred with a probability of survival (Ps) higher than 0.50 and possible preventable death (PP); the deaths occurred with a Ps between 0.50 and 0.25. Deaths in patients with a calculated Ps of less than 0.25 is considered as no-preventable death (NP). A retrospective case review of deaths attributed to mechanical trauma occurring between January 1, 2011 and December 31, 2011 was conducted. RESULTS: A total of 565 consecutive severe trauma patients with ISS>15 or Revised Trauma Score<7 were admitted in our institute. We excluded a total of 24 patients from our analysis : 22 patients younger than 15 years, and 2 patients with burned injury. Of these, 221 patients with head injury were analyzed in the final study. One hundred eighty-two patients were in DP, 13 in PP and 24 in NP. The calculated predicted mortality rates were 11.13%, 59.04%, and 90.09%. The actual mortality rates were 12.64%, 61.547%, and 91.67%, respectively. CONCLUSION: Although it needs to make some improvements, the present study showed that TRISS performed well in predicting survival of traumatic brain injured patients. Also, TRISS is relatively exact and acceptable compared with actual data, as a simple and time-saving method.

Surgical Treatment of Giant Serpentine Aneurysm of A2-A3 Segment Distal Anterior Cerebral Artery : Technical Case Report

OBJECTIVE: To report our surgical experience using in situ end-to-side bypass for giant serpentine distal anterior cerebral artery aneurysm, unsuitable for microsurgical clipping. METHODS: A 49-year-old woman presented with headache and intermittent loss of consciousness. The brain computed tomography scan revealed a partially calcified mass in the interhemispheric fissure. On cerebral angiography, that was giant (30x18 mm sized), serpentine aneurysm originating from the A2 to A3 segment of the distal anterior cerebral artery (DACA). The aneurysm was trapped with clips, and the right A3 segment to left A3 segment of DACA, end-to-side in situ bypass was performed. Surgical result was favorable, with no newly developed ischemic event in the acute recovery period. Postoperative angiography showed total occlusion of the aneurysm and good patency, with preserved distal flow. CONCLUSION: Giant fusiform aneurysms of the DACA are extremely rare and can be particularly challenging to treat. End-to-side A3 : A3 bypass with aneurysm trapping could be a treatment modality for these locations.

Intracranial Meningiomas, WHO Grade Il : Prognostic Implications of Clinicopathologic Features

OBJECTIVE: Intracranial meningiomas are primarily benign tumors with a good prognosis. Although WHO grade II meningiomas are rare (2-10%), WHO grade II meningiomas have higher recurrence and mortality rates than benign. We evaluated the patient recurrence rate and investigated the prognostic factors of WHO grade II meningiomas. METHODS: Between 1993 and 2005, 55 patients were diagnosed with WHO grade II meningiomas in our hospital. WHO grade II meningiomas (n=55) were compared with other WHO grades meningiomas (I, n=373; and III, n=20). The patients had a median age of 48.4 years (range, 14-17 years), a male-to-female ratio of 26 : 29, and a mean follow-up time of 45 months (range, 3-175 months). RESULTS: In WHO grade II meningiomas, only the extent of resection was a significant prognostic factor. Post-operative radiotherapy had no significant influence on tumor recurrence (p=0.053). The relative risk of recurrence was significantly higher in WHO grade II meningiomas with incomplete resection (10/27, RR=37%) than in WHO grade II meningiomas with complete resection (4/28, RR=14%) regardless of post-operative radiotherapy. In the incomplete resection group, Simpson grade III or IV had a significantly high risk of recurrence regardless of post-operative RT (n=3, RR=100%) However, if the degree of resection was Simpson grade II, the recurrence rate was similar to the complete resection group even though post-operative RT was not performed. CONCLUSION: Complete resection was the most powerful independent predictive factor of the recurrence rate in WHO grade II meningiomas. Post-operative adjuvant RT was not a significant factor in this study.

Surgical Results after Unilateral Laminectomy for the Removal of Spinal Cord Tumors

OBJECTIVE: To reduce the risk of postoperative spinal instability or deformity, unilateral laminectomy (UL) has been recommended to remove spinal space-occupying lesions. The purpose of this study was to determine whether there were any advantages of UL for removal of spinal cord tumors. METHODS: From May 1995 to May 2010, 94 patients with spinal cord tumors, who underwent tumor removal via UL in our institute, were enrolled in this study. Intramedullary spinal cord tumors were excluded. Simple radiographs were obtained for accessing the restoration of the spinal column. Spinal magnetic resonance imaging (MRI) was also obtained during the follow-up period to evaluate tumor recurrence. RESULTS: There were 51 women and 43 men; their mean age was 47.8 years (range, 9-83 years). The mean follow-up period was 52.6 months (range, 24 month-16 years). The sites of the tumors were cervical in 21 cases, thoracic in 37, lumbar in 33, and sacral in 3. These cases included 85 intradural extramedullary (IDEM) and 9 extradural (ED) lesions. IDEM tumors consisted mainly of neurilemmomas (56.3%) and meningiomas (22.3%).Tumors were totally removed in 80 cases and subtotally removed in 14 cases. Postoperative neurological status was improved in 53 cases, unchanged in 31 cases, and worsened in 10 cases. During follow-up, MRI showed tumor recurrence in 4 patients. Histopathologically, three cases were meningiomas and one case was neurilemmoma. None of the patients showed spinal instability or kyphotic deformity at last follow-up. CONCLUSION: UL is an optimal approach for providing sufficient exposure of spinal cord tumors without development of postoperative spinal instability and regional sagittal imbalance in any location of spinal column. In cases of meningioma, careful long-term follow up is needed due to it's relatively high recurrence rate after removal via UL.

Early Surgical Results of Carotid Endarterectomy / 대한뇌혈관외과학회지

OBJECTIVES: In this study, we evaluated early surgical results including 30 days early stroke and death rate and complications in 168 cases carotid endarterectomy (CEA). METHODS: A retrospective review of patients who underwent CEA at our institute between September 1999 and August 2010 was done. Preoperative symptoms were stroke in 72 cases, transient ischemic stroke or reversible ischemic neurologic deficit in 56 cases and asymptomatic in 40 cases. Most of the patients had conventional cerebral angiography or neck computed tomography angiography (CTA) for preoperative evaluation. Immediate radiological follow up was performed by neck CTA 1 week postoperatively. RESULTS: The overall postoperative stroke rate including transient ischemic attack within 30 days of the treatment was 1.7%. Major stroke rate with morbidity and death rate within 30 days was 0.6% (1 : major stroke, 1 : death). The cause of death was airway occlusion due to wound hematoma. Cranial nerve palsy developed in two patients (1.1%) and neck hematoma in six patients (3.5%). Neck CTA revealed total occlusion of internal carotid artery in one patient with acute cerebral infarction and then recovered fully. Intracranial hemorrhage relating to the hyperperfusion syndrome developed in one patient. Radiological patency rate was 98.7%. The comparison of 30 days morbidity and mortality rate between CEA and carotid angioplasty and stenting were each 0.6% and 1.5%, but there was no statistical significance. CONCLUSIONS: Carotid endarterectomy provides considerable future risk prevention against stroke in patients with symptomatic and asymptomatic carotid stenosis.

Early Surgical Results of Carotid Endarterectomy / 대한뇌혈관외과학회지

OBJECTIVES: In this study, we evaluated early surgical results including 30 days early stroke and death rate and complications in 168 cases carotid endarterectomy (CEA). METHODS: A retrospective review of patients who underwent CEA at our institute between September 1999 and August 2010 was done. Preoperative symptoms were stroke in 72 cases, transient ischemic stroke or reversible ischemic neurologic deficit in 56 cases and asymptomatic in 40 cases. Most of the patients had conventional cerebral angiography or neck computed tomography angiography (CTA) for preoperative evaluation. Immediate radiological follow up was performed by neck CTA 1 week postoperatively. RESULTS: The overall postoperative stroke rate including transient ischemic attack within 30 days of the treatment was 1.7%. Major stroke rate with morbidity and death rate within 30 days was 0.6% (1 : major stroke, 1 : death). The cause of death was airway occlusion due to wound hematoma. Cranial nerve palsy developed in two patients (1.1%) and neck hematoma in six patients (3.5%). Neck CTA revealed total occlusion of internal carotid artery in one patient with acute cerebral infarction and then recovered fully. Intracranial hemorrhage relating to the hyperperfusion syndrome developed in one patient. Radiological patency rate was 98.7%. The comparison of 30 days morbidity and mortality rate between CEA and carotid angioplasty and stenting were each 0.6% and 1.5%, but there was no statistical significance. CONCLUSIONS: Carotid endarterectomy provides considerable future risk prevention against stroke in patients with symptomatic and asymptomatic carotid stenosis.

Possible Role of Matrix Metalloproteinase in Osteolytic Intracranial Meningiomas

OBJECTIVE: Abnormalities of the bone are frequently encountered in patients with meningioma, and hyperostosis and endostosis are common bone alterations in these tumors. Extensive bony destruction is very unusual in patients with meningioma. We report six cases of intracranial meningioma associated with an osteolytic lesion of the skull and discuss the underlying mechanisms that may be responsible for bone destruction in patients with meningioma. METHODS: Six patients were classified into three groups, severe, moderate and mild, according to the degree of osteolytic bony destruction. The tumor was classified as intracranial or extracranial, depending on its location. We investigated the potential role of matrix metalloproteinase (MMP) in meningioma-associated osteolysis. The levels of MMP expression were determined by gelatin zymography, reverse transcription-quantitative PCR analysis (RT-PCR) and immunohistochemical analysis. RESULTS: Complete surgical removal of the lesion was performed in each patient. Histological examination revealed benign meningioma in four cases, and two cases of atypical meningioma. Patients did not have a poor prognosis except one case of recurred atypical meningioma. Gelatin zymography and RT-PCR detected high levels of MMP-2 in almost all extracranial masses in comparison with the intracranial masses and MMP-9 in two. There was no difference in the severity of bone destruction. Immunohistochemical analysis revealed MMP-2 expression in the vicinity of the bone destruction, and a few MMP-9-positive stainings were observed. CONCLUSION: Osteolysis of the skull in patients with meningiomas might not be indicative of malignant pathological features and poor prognosis. Invasion to the extracranial portion and osteolysis might be associated with MMP-2 expression in meningioma.

A Case of Nicolau Syndrome Treated with Non-steroidal Anti-inflammatory Drug Injection Therapy / 대한피부과학회지

Nicolau syndrome, also known as livedoid dermatitis or embolia cutis medicamentosa, is a rare cutaneous adverse drug reaction characterized by the acute onset of cutaneous and soft-tissue necrosis following intramuscular drug injection. The typical presentation is pain around the injection site, developing into erythema, a livedoid patch, and necrosis of the skin, subcutaneous fat, and muscle tissue. We report a 72-year-old man who presented with a painful, erythematous patch on his left buttock. The patient was treated with non-steroidal anti-inflammatory drug (diclofenac sodium) injection.

A Clinical Study of Efficacy of Surgical Management for Pincer Nails / 대한피부과학회지

BACKGROUND: A pincer nail deformity is characterized by the presence of an excessively curved and distorted nail across the transverse dimension, particularly at the distal part of the nail plate. A multitude of therapeutic modalities has been implemented to treat this condition with limited efficacy. OBJECTIVE: We sought to evaluate the efficacy of surgery of a pincer nail deformity with the use of the modified Haneke's method. METHODS: Six patients (seven toenails and two fingernails) with pincer nail deformities were treated with the modified Haneke's method. Objective assessment was evaluated by use of the width index (width of the nail tip/width of the nail root) and height index (height of the nail tip/width of the nail root). Subjective assessment was evaluated by use of a visual analogue scale declared by patients. In addition, wound complications and recurrence were described. RESULTS: The width index and height index were improved (width index: 15.4%-->7.1%, height index: 63.9%-->1.9%). Relief of pain could be determined in 100% of the cases. For subjective assessment, all of the patients were satisfactory (more than "satisfactory": 100%). There was no recurrence during a 14 to 24 month period (mean time: 19.2 months). CONCLUSION: The modified Haneke's method as a surgical approach might be effective and the procedure is easy to perform for a pincer nail deformity.

VEGF Expression of Cultured Keloid Fibroblasts from Different Donor Sites Under Normoxic and Hypoxic Conditions / 대한피부과학회지

BACKGROUND: The pathophysiological events resulting in keloid formation remain unclear. Overabundant levels of VEGF have been reported to contribute to excessive wound healing. There have been many studies describing the relationship between keloids and VEGF expression. However, there have been no reports about VEGF expression related to donor sites. OBJECTIVE: We investigated VEGF expression of cultured normal and keloid fibroblasts obtained from different body areas under normoxic and hypoxic culture conditions. METHODS: Normal fibroblasts from the earlobe (n=2), shoulder (n=2) and chest (n=2) as well as keloid fibroblasts from the earlobe (n=3), shoulder (n=3) and chest (n=3) were collected and cultured. VEGF expression of fibroblasts at 6 hours, 12 hours, 24 hours and 48 hours for cells maintained under normoxic and hypoxic conditions was measured by the use of RT-PCR. Paraffin-embedded tissues (normal and keloid tissue) were assayed by immunohistochemical staining. RESULTS: For the cultured normal fibroblasts, VEGF expression for cells in the hypoxic condition was higher as compared to VEGF expression in cells in the normoxic condition, irrespective of the donor site and time. However, for the cultured keloid fibroblasts, VEGF expression for cells in the hypoxic condition was higher as compared to VEGF expression in cells in the normoxic condition for cultured shoulder fibroblasts. For each donor site, VEGF expression was highest in the shoulder, followed by the chest and earlobe for cultured normal fibroblasts, irrespective of time. For the cultured keloid fibroblasts, the highest VEGF expression occurred at 6 hours for cells in the normoxic condition and the highest VEGF expression occurred at 6 hours and 12 hours for cells in the hypoxic condition. Based on immunohistochemical staining, VEGF expression of paraffin-embedded normal tissue was lower as compared to paraffin-embedded keloid tissue. For each donor site in paraffin-embedded keloid tissue, VEGF expression was highest in the shoulder, followed by the chest and earlobe. CONCLUSION: Oxygen tension and the nature of fibroblasts from different donor sites are involved in keloid pathogenesis.

Difference of Malassezia Species and Pityrosporum ovale Specific IgE in Head and Neck Lesions of Atopic Dermatitis Related to Ages and Severity / 대한의진균학회지

BACKGROUND: Members of the genus Malassezia, lipophilic yeasts, are considered to be one of the exacerbating factors in atopic dermatitis. When the response of anti-inflammatory treatment of atopic dermatitis to adults was poor, antifungal treatment had a good response to atopic dermatitis. We compared Malassezia species detected in head and neck lesions of atopic dermatitis between children and adults. OBJECTIVE: To compare Malassezia species between children and adults in head and neck lesions of atopic dermatitis and to reveal the correlation levels of P. ovale specific IgE and clinical severity among these groups. METHODS: Malassezia species were incubated in Leeming and Notman media from skin lesions of 28 patients with head and neck lesions of atopic dermatitis (13 children, 15 adults). And ITS1 amplification and sequencing method was done for detection of Malassezia species. We also assayed P. ovale specific IgE and clinical severity grade of the patients. RESULTS: M. globosa was the predominant species in the children group. And M. furfur was the predominant species in the adults group respectively. The levels of P. ovale specific IgE increased more in the adults group than the children group. Clinical severity grade also more increased in the adults group. There was statistically significant correlation between P. ovale specific IgE and clinical severity grade (p<0.001). Conclusion: Malassezia species are aggravating factors in head and neck lesions of atopic dermatitis particularly in adults. We must keep in mind Malassezia species infection when resistance to antiinflammatory therapy in atopic dermatitis of adults.

A Case of Superficial Epithelioma with Sebaceous Differentiation / 대한피부과학회지

Superficial epithelioma with sebaceous differentiation (SESD) is a histologically distinct, rare, benign neoplasm characterized by a superficial plate-like proliferation of basaloid cells with broad attachments to the overlying epidermis. Clusters of sebaceous cells were present within the lobules. We herein report a case of SESD in a 73-year-old female.

A Case of Hypopigmented Mycosis Fungoides / 대한피부과학회지

Hypopigmented mycosis fungoides is a variant of mycosis fungoides. It occurs commonly in younger people and affects those with dark skin. This condition is easily misdiagnosed as vitiligo, postinflammatory hypopigmentation due to its non-specific clinical manifestation. We report a case of hypopigmented mycosis fungoides on both thighs and buttocks in a 44-year-male patient. Histopathologic findings showed Pautrier microabscesses and epidermotropism of atypical lymphocytes in the epidermis. CD8 immunohistochemical staining was positive. After narrow band UVB therapy, the lesions were completely repigmented. There was no evidence of recurrence of lesions after 5 months.

Two Cases of Cutaneous Sinus Tract of Dental Origin / 대한피부과학회지

Cutaneous sinus tract of dental origin usually arises from chronic dental infection. Because many patients with these lesions do not have any complaints of oral symptoms, the lesions are often diagnosed incorrectly and overlooked. We report two cases of cutaneous sinus tract of dental origin. One case on nasolabial fold originated from the maxillary canine periapical abscess. Another case on the mandible originated from the mandibular 2nd premolar periapical abscess. Endodontic root canal therapy resulted in complete healing of the lesions in both cases. Early correct diagnosis and treatment of the lesions can prevent unnecessary and ineffective antibiotic therapy or surgical treatment.

A Case of Milia en Plaque on Upper Extremity / 대한피부과학회지

Milia en plaque is characterized by multiple milia-like lesions within an erythematous plaque. Milia en plaque is a rarely reported entity which usually appears in the auricular region. We report the case of a 72-year-old woman who presented with milia en plaque on the left arm after NSAIDs injection. This is a rare case because there are no records of Milia en Plaque occurring on an arm in Korea.

A Case of Cutaneous Protothecosis / 대한의진균학회지

Cutaneous protothecosis is a rare skin infection, caused by the genus prototheca, especially Prototheca wickerhamii. A 73-year-old woman had a painful, ulcerative patch and oozing plaque on left wrist and dorsum of hand for 2 months. Biopsy specimen revealed thick walled morula-like sporangia in the dermis. P. wickerhamii was isolated in the culture. Oral itraconazole therapy for 8 weeks is not satisfactory. New skin lesion is formed. After oral fluconazole therapy, patient's skin lesion is improved.