PMC7315260_01
(a) Several scars on the patient's back resembling healing of old staphylococcal furunculosis; (b) distal subungual onychomycosis affecting multiple fingernails.
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Upon skin inspection, the patient had several scars on his neck and back (Figure 1(a)), reflecting prior staphylococcal furunculosis previously treated with linezolid. Remarkably, the patient also had onychomycosis (Figure 1(b)), affecting several fingernails and toenails.
Ulcerative and necrotic lesion on the lateral aspect of the right knee measuring 7.5 x 6.0 x 0.1 cm. The wound base was mostly filled with eschar tissue with minimal granulation tissue.
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The primary skin lesion on the lateral aspect of the right knee (Figure 2) was measuring 7.5 cm x 6.0 cm x 0.1 cm.
Punch excision skin biopsy obtained from a right lower extremity ulcer. Digestive PAS stain demonstrating the presence of numerous fungal hyphae consistent with fungal infection. Gram stain appeared negative for bacterial organisms.
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Most remarkably, digestive PAS stain revealed the presence of numerous fungal hyphae consistent with deep fungal infection (Figure 3).
(a) Granulation tissue started to appear and serosanguineous discharge continued to show on the ulcer base (8.1 x 6.4 cm). (b) Progressive healing evidenced by hypergranulation with sloughing around the periphery (no serosanguinous discharge and no eschar tissue). (c) The size of the lesion had significantly reduced to 1.8 x 1.4 cm, and the wound healed completely leaving a pale and raised scar tissue at the site of the lesion.
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Wound debridement was attempted; however, it was initially limited by the thick eschar tissue (Figure 4). One week after initiating treatment, granulation tissues started to appear, and serosanguinous discharge continued to show on the ulcer base (Figure 4). A month later, the ulcer showed hypergranulation with sloughing around the periphery, without eschar tissue or serosanguinous discharge (Figure 4). By the third month, the wound healed completely leaving pale and raised scar tissue at the site of the lesion (Figure 4).