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Presented by Risa Mann, M.D. and prepared by Bahram R. Oliai, M.D.
Case 1: 25-year-old female with a history of renal transplant who developed a large thigh mass.
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1. Question
Week 45: Case 1
25-year-old female with a history of renal transplant who developed a large thigh mass./images/01-16945a.jpg
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/images/01-16945e.jpgCorrect
Answer: Fungal infection, chromoblastomycosis
Histology: The mass consists of a dermal and subcutaneous chronic inflammatory infiltrate composed of numerous giant cells, lymphocytes and polymorphonuclear leukocytes. There is abundant granulation tissue in both the superficial, deep dermis and subcutaneous tissue. The overlying epithelium shows pseudoepitheliomatous hyperplasia. If one looks carefully in the giant cells, one can appreciate the presence of round pigmented objects in many of the giant cells. A fungal stain identifies these rounded objects to stain positively on silver stain indicating that they are fungal organisms. A culture from this lesion also grew out exophiala jeanselmei.
Discussion: The differential diagnosis is between a granulomatous inflammatory process versus a giant cell tumor. The presence of numerous inflammatory cells such as lymphocytes and polymorphonuclear leukocytes indicates that this is most likely an inflammatory pyogranuloma. The presence of numerous giant cells suggests that this is either a giant cell reaction to a foreign object or a fungal infection rather than a pure abscess. Special stains for fungus identified the lesions within the giant cells to indeed be a fungus and cultures were used to further identify the fungus. The dark color of the fungus is due to melanin pigment within the cellular wall of the organism. This organism usually causes chronic fungal infection of the soft tissue and skin. It is a dematiaceous fungus which is found in soil, decaying wood and water. In addition to this specific organism, there are other agents of chromoblastomycosis (also called chromomycosis) that cause pigmented fungal infections. This infection is most common in the tropical and sub-tropical areas. The fungus usually is implanted in the skin through a traumatic implantation. These lesions can become quite large as in this case. In addition to establishing the diagnosis by biopsy or fungal culture, the organisms can be identified from a scraping of the lesion using 20% KOH. The lesions are usually treated with surgical resection. However, some may require long-term antifungal therapy.
Incorrect
Answer: Fungal infection, chromoblastomycosis
Histology: The mass consists of a dermal and subcutaneous chronic inflammatory infiltrate composed of numerous giant cells, lymphocytes and polymorphonuclear leukocytes. There is abundant granulation tissue in both the superficial, deep dermis and subcutaneous tissue. The overlying epithelium shows pseudoepitheliomatous hyperplasia. If one looks carefully in the giant cells, one can appreciate the presence of round pigmented objects in many of the giant cells. A fungal stain identifies these rounded objects to stain positively on silver stain indicating that they are fungal organisms. A culture from this lesion also grew out exophiala jeanselmei.
Discussion: The differential diagnosis is between a granulomatous inflammatory process versus a giant cell tumor. The presence of numerous inflammatory cells such as lymphocytes and polymorphonuclear leukocytes indicates that this is most likely an inflammatory pyogranuloma. The presence of numerous giant cells suggests that this is either a giant cell reaction to a foreign object or a fungal infection rather than a pure abscess. Special stains for fungus identified the lesions within the giant cells to indeed be a fungus and cultures were used to further identify the fungus. The dark color of the fungus is due to melanin pigment within the cellular wall of the organism. This organism usually causes chronic fungal infection of the soft tissue and skin. It is a dematiaceous fungus which is found in soil, decaying wood and water. In addition to this specific organism, there are other agents of chromoblastomycosis (also called chromomycosis) that cause pigmented fungal infections. This infection is most common in the tropical and sub-tropical areas. The fungus usually is implanted in the skin through a traumatic implantation. These lesions can become quite large as in this case. In addition to establishing the diagnosis by biopsy or fungal culture, the organisms can be identified from a scraping of the lesion using 20% KOH. The lesions are usually treated with surgical resection. However, some may require long-term antifungal therapy.
