PMC4735079_01
Examination revealed left lower extremity erythema and edema along with papules, pustules and nodules extending from the left dorsal foot to the left medial thigh (A). Closer examination demonstrated tender papules, some with overlying crust (B).
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From her left dorsal foot to her left medial thigh there was marked woody induration with numerous warm and tender papules, nodules, and several pustules coalescing into larger plaques with sinus tract formation (Fig. 1A and B).
Physical examination of the left lower leg, two days post-debridement (A). Left lower extremity after placement of split thickness skin graft (B), 3 months (C) and 6 months after follow up (D-E).
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Her immunosuppressive therapy was temporarily held, and she underwent extensive surgical debridement followed by split thickness skin grafting (Fig. 2A and B). At follow up seven months later, the patient was doing well with no clinical evidence of recurrence (Fig. 2C-E).
Histologic sections of the punch biopsy show a dense inflammatory infiltrate and numerous granulomas; staining with PAS (A) and GMS stains (B) revealed numerous septate, hyaline hyphae with acute angle branching. Reproductive structures were not identified.
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Periodic acid-Schiff (PAS) and Grocott Methenamine Silver (GMS) staining revealed numerous septate, hyaline hyphae with acute angle branching consistent with phaeohyphomycosis (Fig. 3A and B).
Pictured are colonies (superior (A) and inferior (B) aspects of culture plate shown) with moderate to slow growth in potato dextrose agar at 25  C; colonies are low-lying, velvety, and white-gray to brown. Lactophenol cotton blue stain following growth in cornmeal agar for slide culture at 1 week (C) reveals phialides bearing apical clusters of cylindrical, hyaline conidia and brown septate hyphae consistent with Phaeoacremonium species.
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In slide culture on cornmeal agar at 25  C colonies were initially velvety and white-gray and developed gray-brown pigment and clusters of brown aerial hyphae at one week (Fig. 4A and B). A lactophenol cotton blue mount revealed pigmented septate hyphae with brown, cylindrical, slightly tapered conidiophores with clusters of oblong, hyaline conidia consistent with Phaeoacremonium species (Fig. 4C).