A 65‐year‐old Japanese female farmer had an erythematous, slightly scaly, indurated plaque on the dorsum of the left wrist of more than 3 years’ duration. She had a history of hepatitis C. Her medical history and family history were otherwise unremarkable. The lesion had begun as a small region of erythema on the dorsum of the left wrist 3 years previously and had gradually enlarged. The patient had seen a local physician and had been treated with topical steroids, topical antifungals, and topical vitamin D3 agents without improvement.Initial laboratory studies revealed slightly decreased numbers of white blood cells and thrombocytes, decreased albumin levels, and elevated liver enzymes, reflecting chronic hepatitis C. Clinical examination of the lesion revealed a well‐demarcated, erythematous, slightly scaly, indurated plaque of 22 mm × 28 mm in size on the dorsum of the left wrist (Fig. 1). Superficial lymph nodes were nonpalpable. Direct microscopy revealed aggregates of thick‐walled spores, considered to be sclerotic cells, from which budding brown hyphae emanated (Fig. 2a).A well‐demarcated, erythematous, slightly scaly, indurated plaque of 22 mm × 28 mm in size on the dorsum of the left wristimage(a) Microphotograph of scales in KOH reveals aggregates of thick‐walled, brown sclerotic cells and budding brown hyphae (×400). (b) Conidia are bicellular, gourd‐shaped at maturity and pale brown. They are sympodially produced by darker conidiogenous cells (slide culture, ×400)imageCutaneous biopsy specimens revealed a chronic granulomatous inflammation infiltrated with lymphocytes, histiocytes, neutrophils, and multinucleated giant cells. Within the microabscess and within one of the giant cells were large, brown, thick‐walled cells, which were identified as sclerotic cells, and brown septate hyphae.Culture on a Sabouraud dextrose agar slant at 26 °C yielded villous, green‐tinged, black–gray colonies, with a central button‐like protuberance. By 28 days, these colonies had reached 4.8 cm in diameter. A slide culture showed pale brown septate hyphae bearing lateral and terminal conidiophores. Conidiophores were erect, straight, or flexuous, unbranched or occasionally loosely branched, smooth‐walled, septate, and brown. Conidiogenous cells were terminal or lateral and cylindrical in the apical part with numerous dark brown scars fading away to the apex. Conidia were sympodial and bicellular, with rounded apices and truncated bases (Fig. 2b). On the basis of these morphologic features, we identified the mold as Veronaea botryosa. Surgical excision of the lesion was performed, resulting in complete healing.
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Jan 20, 2013
Le Wang + 11
Open Access