PMC9634954_01
Clinical images of presumed case of emergomycosis, with (a) large crusted facial lesions at initial presentation; (b) a marked improvement following 3 months of oral treatment; (c) minimal residual disease some 7 months later; and (d) complete disappearance of the cutaneous lesions at one year, with mild residual scarring present.
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Physical examination revealed a body mass index (BMI) of 18.1, an inability to open her mouth and crusted blackish and yellowish nodules and plaques involving the face (Figure 1a), limbs and trunk, with stigmata of secondary infection. Three months into her antifungal treatment, most of the facial lesions had healed, with residual scars and presence of lesions only around the mouth and nose (Figure 1b). The fungal infection continued to improve on oral fluconazole therapy (Figure 1c), and at 1-year post-treatment, the facial skin lesions had resolved completely, with minimal scarring (Figure 1d).
Histopathology of presumed Emergomyces africanus infection, with (a) deep dermal and superficial subcutaneous histiocytic and neutrophilic infiltrate in response to the fungal yeasts, with background karyorrhectic debris (haematoxylin and eosin, x 400); (b) pseudoepithelomatous hyperplasis and attempted transepidermal elimination of intracellular and extracellular yeasts (haematoxylin and eosin, x 400); (c) periodic acid-Schiff stain highlighting the predominantly intracellular organisms in the upper dermis (periodic acid-Schiff, x 1000); and (d) Gomori methamine silver stain confirming transepidermal elimination of extracellular yeasts into the stratum corneum (Gomori methamine silver, x 1000).
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Occasional lymphocytes and neutrophils were also evident amid the background necrotic and karyorrhectic cellular debris (Figure 2a). The overlying epidermis demonstrated striking pseudo-epitheliomatous hyperplasia, with intra-epidermal organisms and transepithelial elimination of the fungi (Figure 2b). These organisms were highlighted on histochemical staining with periodic acid-Schiff (Figure 2c) and Grocott methenamine silver (Figure 2d).