PMC10052466_01
Extensive superficial pustules on a background of erythema, erosion and scale on the (a) Axillary vault, (b) Superior aspect of buttocks, (c) Back and (d) Lateral aspect of buttocks.
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I, with widespread symmetric erythema in folds extending to the back, with innumerable superficial pustules, erosion, and scale (Figure 1(a)-(d)). In addition, there was a large sacral pressure ulcer spreading to the scrotum with surrounding dusky erythema, scale, and pustules.
(a) Direct bedside KOH exam revealing branched hyphae. (b) Fungal spores and hyphae on PAS stain (original magnification 600x). (c) Corneal pustule centered over a follicle, with mild superficial perivascular inflammation and acanthosis (H&E, original magnification 40x). (d) Fungal hyphae can be seen within the pustule (H&E, original magnification 400x).
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While the initial differential included AGEP from one of his recent antibiotics, a bedside KOH exam of a skin scraping from some pustules revealed branched hyphae, confirming superficial fungal infection, either dermatophyte or Candida spp (Figure 2(a)). This was also noted later in the laboratory by direct microscopy (Figure 2(b)). A punch biopsy of a pustule on the abdomen was also performed for H&E and direct immunofluorescence (DIF) (Figure 2(c) and (d)).