First reported case of Aspergillus nidulans eumycetoma in a sporotrichoid distribution.

BACKGROUND: Mycetomas are chronic subcutaneous infections caused by either fungi (eumycetomas) or bacteria (actinomycetomas). Eumycetoma is commonly seen in tropical and subtropical climates, usually in males working in occupations prone to trauma. Aspergillus spp. are an uncommon cause of mycetomas. OBJECTIVES: We describe a patient with eumycetoma attributable to Aspergillus nidulans presenting in a sporotrichoid distribution. CASE REPORT: A 45-year-old man with type 2 diabetes mellitus and hypertension presented with multiple lumps over the right lower limb of four months in duration. He had initially developed a solitary lesion over the right ankle, followed by multiple similar lumps which had spread upwards to involve the right thigh. The entire lower limb was edematous. The patient denied any trauma preceding the symptoms. Biopsy revealed pseudoepitheliomatous hyperplasia with extensive granulomatous infiltrate in the dermis and subcutaneous tissue. Grocott-Gomorri staining revealed fungal elements. Culture on Sabouraud's agar revealed a whitish colony that later turned green. Aspergillus nidulans mycetoma in a sporotrichoid distribution was diagnosed. The patient was started on oral itraconazole 200 mg twice daily, which resulted in complete regression of the lesions. CONCLUSIONS: Aspergillus spp. have emerged as important opportunistic pathogens, especially in immunosuppressed patients. Aspergillus nidulans occurs frequently in soil, decaying vegetation, and water but has very rarely been described as a cause of mycetoma. The infection responds well to treatment with itraconazole, voriconazole, and amphotericin B. The current patient represents the first demonstration of A. nidulans mycetoma presenting in a sporotrichoid distribution.

Rare case of primary cutaneous mucormycosis of the hand caused by Rhizopus microsporus in an immunocompetent patient.

BACKGROUND: Primary cutaneous mucormycosis is a very uncommon manifestation occurring most often in diabetics or following trauma. METHODS AND RESULTS: We herein present a case of primary cutaneous mucormycosis of the hand caused by Rhizopus microsporus in an immunocompetent patient. CONCLUSION: This is the second such reported case in the literature.

Rare atypical presentations in Type 2 lepra reaction: a case series.

OBJECTIVES: Type 2 lepra reaction is a Th2-mediated type III hypersensitivity reaction in leprosy, with a characteristic cutaneous manifestation in the form of erythema nodosum leprosum (ENL). We describe unusual presentations of Type 2 lepra reaction in five patients. METHODS: Patient data and dermatological findings were analyzed in three men and two women diagnosed with Hansen's disease. RESULTS: Findings included multiple tender, polycyclic, necrotic lesions distributed over the face in one patient, and painful, fluid-filled lesions on both arms and lower limbs in another. The third patient showed erythematous, tender nodules, bullae, and necrotic ulcers over the back and upper and lower limbs. The fourth showed erythematous tender nodules over the face, neck, back, and extremities, predominantly in sun-exposed areas. The fifth revealed multiple erythematous, severely tender nodules and urticarial plaques mimicking those of Sweet's syndrome. Diagnosis of borderline or lepromatous leprosy with atypical Type 2 reaction were made in all cases. CONCLUSIONS: Type 2 lepra reactions are antigen antibody-mediated immune complex reactions that present with constitutional symptoms and ENL characterized by tender, erythematous, evanescent nodules mainly on the face, arms, and legs. Over 50% of lepromatous leprosy patients and 25% of borderline lepromatous leprosy patients experienced type 2 lepra reactions prior to the advent of multi-drug therapy. Thalidomide is the drug of choice for severe atypical lepra reactions because of its anti-tumor necrosis factor-α action. Awareness of these atypical variants and prompt diagnosis and treatment are essential to prevent mortality and morbidity in potentially treatable patients.

First reported case of subcutaneous hyalohyphomycosis caused by Paecilomyces variotii.

BACKGROUND: Hyalohyphomycosis is a rare opportunistic fungal infection caused by saprophytes of genera such as Fusarium, Paecilomyces, Scedosporium, Penicillium, Scopulariopsis Acremonium, and similar fungi. The literature includes only one previous report of Paecilomyces variotii human infection and very few reports of subcutaneous mycosis caused by any of the hyalohyphomycosis group of fungi. METHODS: We report an instance of fungal infection in a 50-year-old woman, known to have diabetes, who presented with multiple raised lesions on the upper back of two years' duration. Dermatological examination revealed a 20 × 22-cm, swollen, indurated area on the upper back with multiple violaceous, exophytic nodules on the surface. RESULTS: Microscopy from pus and tissue smear revealed septate branching fungi. Periodic acid Schiff (PAS) stain was positive for fungal elements. Culture on three occasions yielded P. variotii. Slide culture mounts showed septate hyaline hyphae of P. variotii with elongated phialides demonstrating bulbous bases and tapering apices attached to the conidiophores. The patient was treated with itraconazole, to which she responded well. CONCLUSIONS: This is the first reported case of subcutaneous hyalohyphomycosis caused by P. variotii. It appears that this relatively rare fungal pathogen may be starting to assert itself as an important cause of infection in humans.