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Indian Journal of Dermatology, Venereology and Leprology, Vol. 71, No. 4, July-August, 2005, pp. 305-306 Quiz Subcutaneous cystic swelling in a leprosy patient Kar BikashRanjan, Ebenezer G., Job C.K. Department of Dermatology, Schieffelin Leprosy Research & Training Centre, Karigiri, Vellore Code Number: dv05103 A 45-year-old male attended the hospital with complaints of a subcutaneous swelling over the dorsum of the right hand since 6 months. He had been diagnosed as a case of lepromatous leprosy 4 years earlier and treated with the WHO multibacillary multidrug regimen for 24 months. After 6 months of starting MDT, the patient started getting recurrent erythema nodosum leprosum for which he received systemic prednisolone off and on. He developed the subcutaneous swelling while on oral corticosteroid treatment (Total cumulative dose of 12600 mg in last 2 years with maximum dose of 40 mg per day) for control of type II lepra reaction. There was no history of trauma preceding the onset of the lesion. What is your diagnosis? Diagnosis: Subcutaneous phaeohyphomycosisDISCUSSION Histopathology revealed a cystic cavity containing necrotic material. The wall was composed of dense fibrous tissue, epithelioid cells, numerous Langhans and foreign body giant cells and lymphocytes [Figure - 2].Numerous fungal hyphae were present in the inflammatory infiltrate. They were broad, haphazardly branched and the walls varied in shape and thickness. Periodic acid Schiff (PAS) stain clearly demonstrated the presence of fungal hyphae [Figure - 3]. Culture for fungus showed growth of Exophiala jeanselmei . The term "phaeohyphomycosis" was coined in 1974 to describe infections with dematiaceous, septate mycelial elements in the tissue.[1] Though subcutaneous phaeohyphomycosis is more common in the tropics and in immunosuppressed patients on prolonged steroid therapy[2], it may also occur in immunocompetent persons.[3] Phaeohyphomycosis is a rare, and usually localized, subcutaneous or intramuscular infection, typically a cyst or abscess, caused by any one of over a 100 species[4] of dematiaceous fungi. Common causes are Exophiala jeanselmei , Exophiala dermatitidis and Bipolaris. Recently, Girard et al[5] reported a case of subcutaneous phaeohyphomycosis caused by Pyrenochaeta romeroi in a leprosy patient. The pathogen is probably by implantated from an exogenous source. Infection begins with a firm, sometimes tender nodule, which may develop into a large cyst up to several centimeters in size. Histopathology with the help of special fungal stains like PAS and Grocott′s stains will help confirm the diagnosis. It is important to exclude other cystic structures such as Baker′s cysts. The fungi can be seen in the granulomatous lining of the cyst wall. The organisms are not usually difficult to grow from the lesion, but identification of the subspecies sometimes requires help from a specialist. The usual treatment is surgical excision. Itraconazole is often recommended after surgery to reduce the chances of recurrence, particularly in immunosuppressed patients.[6] REFERENCES
Copyright 2005 - Indian Journal of Dermatology, Venereology and Leprology The following images related to this document are available:Photo images[dv05103f3.jpg] [dv05103f2.jpg] [dv05103f1.jpg] |
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