Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_182_библиотеки_им_акад_М_И_Перельмана.pdf
MYCETOMA
Mycetoma of the foot from a patient stationed in
Guam demonstrates several draining sinus tracts
(present for months) with tissue swelling and slight
hyperpigmentation. (Courtesy J. Steger, MD.)
Fungal Infections: Morphological Diagnosis of Fungal Infections
TERMINOLOGY
Synonyms
Eumycetoma (fungal origin): Eumycotic mycetoma,
mycotic mycetoma, Madura foot
Actinomycetoma (bacterial orgin): Actinomycotic
mycetoma
Definitions
Greek: "mykes" (fungus, mushroom) + "oma" (morbid
growth)
ETIOLOGY/PATHOGENESIS
Infectious Agents
Actinomycetoma (grains of various colors but not
black): Caused by bacteria
Common etiologic agents: Nocardia spp.,
Actinomadura spp., Streptomyces spp.
Eumycetoma: Caused by at least 30 hyaline and
pigmented species of fungi
Etiologic agents of black grains/granules
Most common (90% of cases): Madurella
mycetomatis, Madurella grisea, Leptosphaeria
senegalensis
Less common: e.g., Pyrenochaeta romeroi,
Cladophialophora bantiana, Exophiala jeanselmei
Etiologic agents of white/yellow/green/brown
grains/granules
Most common: Pseudoallescheria boydii
Less common: e.g., Acremonium spp., Fusarium
spp., Aspergillus spp.
Skin and subcutaneous infection occurs via direct
inoculation of organisms through contact with
contaminated materials
III
Mycetoma can be caused by actinomycetes
(actinomycetoma) . Filamentous bacteria (usually 1
m) will stain positively on Gram. Culture differentiates it
from eumycetoma. (Courtesy M. Chaffins, MD.)
CLINICAL ISSUES
Epidemiology
Worldwide but endemic in tropical and subtropical
areas
Risk factors: Environmental exposure to pathogenic
organisms, genetic predisposition to infection,
immunosuppression
Presentation
Feet >> hands, legs, and knees
Clinical triad: Swollen tissue, draining sinuses,
presence of grains from draining discharge
Secondary bacterial infection and local
lymphadenopathy are common
If untreated, involvement of bone, tendon, nerves
may occur
Treatment
Actinomycetoma: Antibacterials, depending on
causative agent
Eumycetoma: Both medical (usually ketoconazole or
itraconazole) and surgical interventions
Prognosis
Actinomycetoma: More rapid clinical progression
If no treatment is given, severe local tissue destruction
and debilitation requiring surgical amputation may
develop
MICROBIOLOGY
Culture
Routine fungal cultures (eumycetoma) and anaerobic
and aerobic bacterial cultures (actinomycetoma) for
speciation
Time consuming and subject to contamination
1
42
Etiology
Actinomycetoma: Caused by bacteria
Eumycetoma: Caused by fungi
Clinical Issues
Skin and subcutaneous infection occurs via direct
inoculation of organisms
Occurs worldwide but endemic in tropical and
subtropical areas
Feet >> hands, legs and knees
Clinical triad: Swollen tissue, draining sinuses,
presence of grains from draining discharge
Macroscopic Pathology
Small, subcutaneous skin nodules become flocculent
with time; purulence may ooze with grains from skin
surface as swellings break open
MYCETOMA
Key Facts
Chronic lesions may become firmer with fibrosis and
sclerosis
Microscopic Pathology
Actinomycetoma: Colored grains with fine ( 1 m)
radially oriented filaments
Eumycetoma: Colored grains with septate hyphae
(2-6 m in diameter) accompanied by numerous
chlamydoconidia and swollen cells
Ancillary Tests
Actinomycetoma: Gram(-) centers with gram(+)
fringes
Eumycetoma: Gram(-)
Top Differential Diagnoses
Sporotrichosis, chromoblastomycosis,
phaeohyphomycosis, tuberculosis, soft tissue tumors
Fungal Infections: Morphological Diagnosis of Fungal Infections
MACROSCOPIC FEATURES
Gross Appearance
Small, subcutaneous skin swellings become flocculent
with time; purulence admixed with grains ooze from
skin surface as swellings break open
Chronic lesions may become firmer with fibrosis and
sclerosis
MICROSCOPIC PATHOLOGY
Histologic Features
Actinomycetoma: Colored grains (various colors but
not black) composed of fine ( 1 m) radially oriented
filaments
Eumycetoma: Colored grains (various colors including
black) containing variously shaped septate hyphae
(2-6 m in diameter) accompanied by numerous
chlamydoconidia and swollen fungal cells
Draining sinus tracts with abscesses containing grains
and necrotic debris fibrosis (chronic)
Cytologic Features
Smears of grains from oozing sinuses may reveal
bacteria or fungi for diagnosis
ANCILLARY TESTS
Histochemistry
Actinomycetoma: Grains have gram-negative centers
with gram-positive radiating fringes
Eumycetoma: Gram-negative
Silver stains and periodic acid-Schiff stains highlight
both types of organisms
Molecular Diagnostics
PCR-based assays against certain causative agents have
been developed
DIFFERENTIAL DIAGNOSIS
Sporotrichosis
Mixed suppurative and granulomatous inflammation
with lack of grains
Botryomycosis
Mixed suppurative and granulomatous inflammation
with grains composed of bacterial cocci or rods
(nonfilamentous)
Chromoblastomycosis
Presence of sclerotic bodies and lack of grains
Phaeohyphomycosis
Granulomatous inflammation with suppurative
exudate but no grain formation
Tuberculosis
Absence of grain formation
Spindle Cell Sarcoma
Exhibits malignant morphologies (pleomorphism,
mitoses, necrosis) and lack grains
DIAGNOSTIC CHECKLIST
Clinically Relevant Pathologic Features
Draining sinus tracts with grains and necrotic debris
Pathologic Interpretation Pearls
Actinomycetoma: Fine, radially oriented bacterial
filaments
Eumycetoma: Septate hyphae with numerous
chlamydoconidia and swollen cells
SELECTED REFERENCES
1. Bonifaz A et al: Mycetoma: experience of 482 cases in a
single center in Mexico. PLoS Negl Trop Dis. 8(8):e3102,
2014
2. Lichon V et al: Mycetoma : a review. Am J Clin Dermatol.
7(5):315-21, 2006
III
1
43
Gross and Microscopic Features
g
g
(Left) This patient with
mycetoma presented with a
hyperpigmented, edematous,
boggy medial ankle with
multiple sinus tracts
indicative of Madura foot.
(From DP: Nonneoplastic
Derm.) (Right) Although
usually more deep seated,
characteristic pale grains of
eumycetoma are seen
surrounded by inflammation.
(Courtesy S. Florell, MD.)
Fungal Infections: Morphological Diagnosis of Fungal Infections
(Left) Medium magnification
of scalp mass excision on
H&E stain shows pale grains
associated with abscess
formation and giant cell
ranulomatous inflammation.
Irregular hyphal and yeastlike forms are present within
the granules. Findings are
consistent with eumycetoma.
(Right) Medium magnification
of a skin section on H&E stain
shows grains composed of
thick short hyphae mixed
with numerous swollen cells
consistent with eumycotic
mycetoma. Culture is needed
for speciation.
MYCETOMA
(Left) High magnification of a
rain shows very fine radiating
filaments. Differentials include
actinomycosis (acid-fast
negative) vs. actinomycotic
mycetoma caused by Nocardia
spp. (partially acid-fast).
(Right) PAS stain highlights
numerous swollen cells/
chlamydoconidia and short
hyphae in this fungal grain.
III
1
44
Microscopic Features
p
g
p
g
p
Fungal Infections: Morphological Diagnosis of Fungal Infections
MYCETOMA
(Left) Low-power view from
a patient with mycetoma
due to Nocardia spp. shows
several nodules in the
mid dermis with layered
neutrophilic (suppurative)
& granulomatous
inflammation surrounding
sulfur granules . (From
DP: Nonneoplastic Derm.)
(Right) High-power view
of a eumycetoma reveals
neutrophils and chronic
inflammatory cells in
association with pale grains
, which usually stain light
ink or light purple on H&E.
(From DP:Nonneoplastic
Derm.)
(Left) Eumycetoma can
have either black or pale
rains. Pale grains can also
be seen in actinomycetoma,
but black grains (which
stain brown on H&E)
are characteristic of
eumycetoma. (From DP:
Nonneoplastic Derm.)
(Right) This image shows
characteristic black grains
(brown on H&E) of
eumycetoma surrounded
by acute inflammation.
Note how the filamentous
fungi form a thick mass.
(Courtesy C. Rosales, MD.)
(Left) High-power view of a
ale grain of eumycetoma
demonstrates a dense mass
of intermeshing hyphae
in intercellular cement.
(From DP: Nonneoplastic
Derm.) (Right) Medium
magnification of skin biopsy
on GMS stain highlights a
rain with numerous swollen
cells and hyphae with
closely spaced septations.
Differentials include
haeohyphomycosis vs.
aspergillosis.
III
1
45
PARACOCCIDIOIDOMYCOSIS
Methenamine silver stain of P. braziliensis in tissue
biopsy demonstrates the "ship’s wheel" appearance .
(Courtesy Franz von Lichtenberg Collection of Infectious
Disease Pathology, BWH.)
Fungal Infections: Morphological Diagnosis of Fungal Infections
TERMINOLOGY
Synonyms
Brazilian blastomycosis
South American blastomycosis
Lutz-Splendore-de Almeida disease
Definitions
Coccidioides: Greek "kokkos" meaning "berry"
Para: Greek "para" meaning "beside or near"
ETIOLOGY/PATHOGENESIS
Infectious Agents
Paracoccidioides brasiliensis
Thermally dimorphic fungus
Yeast at 37C, mycelium at 22-26C
CLINICAL ISSUES
Epidemiology
Present in Central and South America (endemic in
some regions)
80% of cases are reported in Brazil
Columbia and Venezuela have next highest rate of
incidence
Most common cause of systemic mycoses in these
regions
More common in men
Male-to-female ratio is 13:1 in Brazil and may be
even higher elsewhere
Estradiol may be protective against establishment of
chronic disease
Presentation
III
Most commonly asymptomatic lung infection
following inhalation
Juvenile form (acute/subacute paracoccidioidomycosis)
1
Methenamine silver stain of P. braziliensis from
bronchoalveolar lavage fluid demonstrates the
characteristic "ship’s wheel" appearance .
Accounts for < 10% of all paracoccidioidomycosis
infections
Most common in children and adults under age of
30
Skin lesions, lymphadenopathy,
hepatosplenomegaly, anemia, eosinophilia
Chronic form
Majority have lung involvement with cough and
dyspnea, rarely hemoptysis
Associated with fever, malaise, weight loss, and
lymphadenopathy
50% have mucosal involvement (painful
ulcerations)
Skin lesions (ulcers, plaques, verrucous lesions)
CNS involvement (most common in patients with
concomitant HIV infection)
Treatment
Itraconazole and other azoles (for mild to moderate
disease)
Amphotericin B (for severe disease including CNS
involvement)
Terbinafine
Prognosis
Sequelae of disease can have high morbidity including
pulmonary fibrosis following lung involvement and
Addison disease following adrenal involvement
IMAGE FINDINGS
CT Findings
Pulmonary ground-glass opacities (alveolar and
interstitial infiltrates)
Reversed halo sign
Fibrosis and emphysematous changes may be present
in chronic disease
46
PARACOCCIDIOIDOMYCOSIS
Etiology
Thermally dimorphic fungus
Clinical Issues
Present in Central and South America
Male-to-female ratio is 13:1 in Brazil and may be even
higher elsewhere
MICROBIOLOGY
Fungal Features
Yeast form
Oval to round yeast with narrow-based, budding
conidia ("ship’s wheel" appearance)
Mycelial form
Septate, thin hyphae (sometimes with conidia)
White, compact colonies grow on Sabouraud dextrose
agar (slow growing, ~ 20 days)
MICROSCOPIC PATHOLOGY
Key Facts
Microscopic Pathology
Large, round yeast cells with multiple narrow-based,
budding yeasts ("ship’s wheel" appearance)
Granulomatous inflammation
Multinucleated giant cells
Can look similar histologically to Blastomyces
dermatitidis but B. dermatitidis will have only a single
budding yeast and P. brasiliensis will have multiple
Noninfectious Causes
Wegener granulomatosis
Sarcoidosis
Lymphoma
Fungal Infections: Morphological Diagnosis of Fungal Infections
Differentiate based on geographical distribution,
serology and histopathology
Coagulative necrosis with angiitis and palisading
histiocytes
Noncaseating granulomas with scattered giant cells
and asteroid bodies
Monotonous lymphocytic infiltrate replacing
normal lymph node architecture
Histologic Features
Skin scrapings can be examined using KOH
preparation
Methenamine silver stain or periodic acid-Schiff digest
for histology visualization
Large, round yeast cells with multiple narrow-based,
budding yeasts ("ship’s wheel" appearance)
Granulomatous inflammation
Acute inflammation with multinucleated giant cells
surrounding organisms
DIFFERENTIAL DIAGNOSIS
Infectious Causes
Blastomycosis, lobomycosis, leishmaniasis,
tuberculosis, histoplasmosis
IMAGE GALLERY
DIAGNOSTIC CHECKLIST
Pathologic Interpretation Pearls
Consider in male from endemic area
Conversion to yeast phase at 37C following culture at
lower temperatures
Can look similar histologically to Blastomyces
dermatitidis but B. dermatitidis will have only a single
budding yeast and P. brasiliensis will have multiple
SELECTED REFERENCES
1. Bocca AL et al: Paracoccidioidomycosis: eco-epidemiology,
taxonomy and clinical and therapeutic issues. Future
Microbiol. 8(9):1177-91, 2013
2. Brummer E et al: Paracoccidioidomycosis: an update. Clin
Microbiol Rev. 6(2):89-117, 1993
(Left) Proliferating yeast forms of Paracoccidioides braziliensis are seen at medium power. (Center) Proliferating yeast forms of
Paracoccidioides braziliensis
(Right) Methenamine silver stain of P. braziliensis shows "ship’s wheel"
are seen at high power. (Courtesy Franz von Lichtenberg Collection of Infectious Disease Pathology, BWH.)
and other yeast forms .
III
1
47
PENICILLIOSIS
Penicillium fungal culture shows powdery colonies (most
species are green), which are a source of penicillin
antibiotic. Reddish pigment signifies P. marneffei, a less
common but pathogenic species.
Fungal Infections: Morphological Diagnosis of Fungal Infections
TERMINOLOGY
Synonyms
Penicillium marneffei infection
Definitions
Latin: "Penicillus" (paintbrush) + Marneffe (from
Hubert Marneffe, director of Pasteur Institute)
ETIOLOGY/PATHOGENESIS
Environmental Exposure
Environmental source is soil and rats
Endemic in Southeast Asia
Patients with immunocompromise are particularly
at risk for disseminated disease
Travel to Southeast Asia or origins in Southeast Asia
for affected patients is very common and should
suggest diagnosis
Infectious Agents
P. marneffei
Thermally dimorphic fungus (only one
among Penicillium species) that causes
localized (immunocompetent) or disseminated
(immunosuppressed) disease
Cultured Penicillium species grown at 25 C on toluidine
blue stain show conidiophores with terminal metulae
, each having ~ 5 phialides , common among all
species.
Cases reported in Europe and United States are
almost always in immunosuppressed patients with
travel to endemic areas
Penicillium other than P. marneffei have produced < 30
total cases of infection in literature
Presentation
Nonspecific reticuloendothelial cell infection (should
highly suspect with travel history)
Dyspnea, cough, fever
Generalized lymphadenopathy, hepatosplenomegaly
Diarrhea
With dissemination, skin, joints, and bone may
become infected
Papules on face, chest, arms, and legs may occur in ~
70% of disseminated patients
Appear similar to lesions of molluscum
contagiosum
Laboratory Tests
Blood cultures from patients with disseminated disease
will show hyphal forms
Other fluids that may be infected include urine,
stool, and cerebrospinal fluid
28S rRNA conserved primers with sequencing or P.
marneffei-specific primers (with no culture available
or directly on tissue)
III
1
48
CLINICAL ISSUES
Epidemiology
Systemic disease is almost exclusively in
immunosuppressed patients, although
immunocompetent may have limited localized disease
Endemic to Indonesia, China, Vietnam, and Thailand
as well as possibly in Cambodia, Laos, Myanmar, and
Malaysia
Treatment
Initially amphotericin B followed by long-term
itraconazole
Prognosis
Response to treatment is 60-80%
Terminology
Penicillium marneffei infection
Etiology
Endemic in Southeast Asia
Thermally dimorphic fungus
Clinical Issues
Systemic disease in immunosuppressed patients
Blood cultures will show hyphal forms
MICROBIOLOGY
Culture
At 25-30 C, on Sabouraud dextrose agar, produces
flat, powdery to velvety colonies within 3 days (rapid
grower)
Microscopically composed of conidiophores with
several metulae that end in multiple phialides
At 35-37 C, inhibitory mould agar or brain heart
infusion agar produces soft, dry, yeast-like colonies
Hyphal elements with fragmenting ends that
produce arthroconidia (yeast-like capsules)
PENICILLIOSIS
Key Facts
Microscopic Pathology
~ 5 m capsular-shaped yeast-like arthroconidia with
central septa
Macrophage (early), acute inflammation/necrosis/
abscess, chronic granulomatous inflammation
Top Differential Diagnoses
Histoplasmosis
Leishmaniasis
Artifacts
Macrophages are usually present in early lesions
Acute inflammation with necrosis may develop with
frank abscesses
Chronic inflammation produces granulomatous
lesions with scarring/fibrosis without calcification
DIFFERENTIAL DIAGNOSIS
Histoplasmosis
Histoplasma capsulatum produce small round yeast
forms, distinct halo in macrophages, reproduce by
budding, and produce calcifications in chronic lesions
Fungal Infections: Morphological Diagnosis of Fungal Infections
MICROSCOPIC PATHOLOGY
Histologic Features
Organisms are ~ 5 m capsular-shaped yeast-like
arthroconidia
Divide by binary fission with prominent central
septa
Routine H&E stain may produce a false capsule
(confusing with Histoplasma)
Silver stains and periodic acid-Schiff stain highlight
arthroconidia
Affected tissue may have a variable inflammatory
reaction, depending on immunosuppressed state
Affected organs include skin, bone marrow, lung,
gastrointestinal tract, lymph nodes, and most other
organs
MICROSCOPIC FEATURES
Leishmaniasis
Leishmania species are kinetoplastid parasites found
within macrophages and have a distinctive dot-dash
(nucleus-kinetoplast) morphology
Artifacts
Intracytoplasmic macrophage material will lack central
septa/be less uniform
SELECTED REFERENCES
1. Wong KH et al: Twenty years of clinical human
immunodeficiency virus (HIV) and acquired
immunodeficiency syndrome (AIDS) in Hong Kong. Hong
Kong Med J. 12(2):133-40, 2006
2. Nittayananta W: Penicilliosis marneffei: another AIDS
defining illness in Southeast Asia. Oral Dis. 5(4):286-93,
1999
(Left) Diff-Quik-stained aspirate contains collections of yeast-like arthroconidia consistent with Penicillium marneffei (confirmed by culture).
(Center) Gastrointestinal tract biopsy in disseminated Penicillium marneffei shows dense acute/chronic inflammation, expansion of the lamina
propria, and loss of crypts. Organisms were seen on silver stain. (Right) Capsule-shaped yeast-like arthroconidia of Penicillium marneffei
divide by binary fission (no budding).
III
1
49
PHAEOHYPHOMYCOSIS
Tissue section from a patient with phaeohyphomycosis
demonstrates numerous pigmented fungal forms
admixed with neutrophil, necrosis, and foreign material.
Fungal Infections: Morphological Diagnosis of Fungal Infections
TERMINOLOGY
Synonyms
Phaeosporotrichosis, phaeomycotic cyst,
chromomycosis (obsolete)
Cerebral chromomycosis, cerebral dematiomycosis
Definitions
Greek: "Phaeo" (dusky, dark, twilight) + "hypho" (net)
+ "mykos" (fungus)
ETIOLOGY/PATHOGENESIS
Environmental Exposure
Ubiquitous organisms associated with soil and wood
Inoculation of localized disease can occur with
splinters or plant fragments in lesions
Disseminated disease &/or cerebral disease associated
with inhalation of organisms from environment
(without primary lung pathology)
Infectious Agents
> 100 species of dematiaceous (pigmented, specifically
with melanin) fungi can cause phaeohyphomycosis
Important genera include Alternaria, Exophiala,
Phialophora, Wangiella, Bipolaris, Curvularia, and
Exserohilum
CLINICAL ISSUES
Presentation
Localized disease of skin presents with swelling,
induration, or mass (history of trauma)
Disseminated disease most commonly presents with
neurological symptoms (brain is most commonly
III
involved) but other organs can be involved
A granulomatous reaction in the skin of a patient with
phaeohyphomycosis shows numerous pigmented fungal
forms including chains of yeast .
Treatment
Surgical removal/debridement/drainage of localized
skin disease or brain lesions aids in diagnosis and
therapy
Antifungals (itraconazole &/or amphotericin B)
Prognosis
Localized disease responds to antifungal therapy &/or
surgical intervention
Disseminated disease, especially in
immunosuppressed, may be difficult to treat, and fatal
MICROBIOLOGY
Culture
Due to large number of potential organisms, culture
(or PCR) required for speciation
Routine fungal cultures (Sabouraud dextrose agar,
brain-heart infusion agar, corn meal agar, potato
dextrose agar) are primary media at multiple
temperatures
MICROSCOPIC PATHOLOGY
Histologic Features
Granulomatous inflammation, often cystic, with
necropurulent debris
Fragments of foreign material (wood or plant) are
often found in primary lesions
Disseminated lesions (brain, sites other than skin)
will not contain foreign material
Organisms appear as pigmented yeast in chains to
hyphal forms within/around granulomatous reaction
1
50
PHAEOHYPHOMYCOSIS
Etiology
Inoculation with splinters or plant fragments in
lesions
Disseminated disease &/or cerebral disease with
inhalation
> 100 species of dematiaceous (pigmented,
specifically with melanin) fungi
Clinical Issues
Skin: Swelling, induration, or mass with trauma
Key Facts
Disseminated: Neurological symptoms
Microscopic Pathology
Cystic granulomatous inflammation with
necropurulent debris
Pigmented yeast in chains to hyphal forms
Top Differential Diagnoses
Chromoblastomycosis
Aspergillosis
Fungal Infections: Morphological Diagnosis of Fungal Infections
ANCILLARY TESTS
Histochemistry
Fungal elements will be positive on standard fungal
stains including silver and periodic acid-Schiff
Melanin in walls of fungi may stain strongly with
Fontana-Masson stain (variable)
PCR
Molecular identification of fungi by 28S rRNA PCR
with sequencing is more rapid than culture methods
DIFFERENTIAL DIAGNOSIS
Chromoblastomycosis
"Copper pennies" or double septate forms; does not
disseminate
Aspergillosis
Some species of Aspergillus are pigmented in tissue
(usually Aspergillus terreus)
DIAGNOSTIC CHECKLIST
Pathologic Interpretation Pearls
Pigmented, visible hyphal forms in tissue should
suggest diagnosis
SELECTED REFERENCES
1. Fernandez-Flores A et al: Morphological findings of
deep cutaneous fungal infections. Am J Dermatopathol.
36(7):531-53; quiz 554-6, 2014
2. Schieffelin JS et al: Phaeohyphomycosis fungal infections
in solid organ transplant recipients: clinical presentation,
pathology, and treatment. Transpl Infect Dis. 16(2):270-8,
2014
3. Sato T et al: A case of phaeohyphomycosis of
the face caused by Exophiala oligosperma in an
immunocompromised host. J Dtsch Dermatol Ges.
11(11):1087-9, 2013
4. Severo CB et al: Phaeohyphomycosis: a clinicalepidemiological and diagnostic study of eighteen cases
in Rio Grande do Sul, Brazil. Mem Inst Oswaldo Cruz.
107(7):854-8, 2012
5. Singh G et al: Chronic disfiguring facial lesions in an
immunocompetent patient due to Exophiala spinifera:
a case report and review of literature. Mycopathologia.
174(4):293-9, 2012
6. Hoffmann Cde C et al: Infections caused by dematiaceous
fungi and their anatomoclinical correlations. An Bras
Dermatol. 86(1):138-41, 2011
7. Koo S et al: Fonsecaea monophora cerebral
phaeohyphomycosis: case report of successful surgical
excision and voriconazole treatment and review. Med
Mycol. 48(5):769-74, 2010
IMAGE GALLERY
(Left) Low magnification shows cellulitis , panniculitis , and giant cell reaction in a patient with phaeohyphomycosis. (Center) Within
this area of neutrophilic inflammation and necrosis, numerous pigmented fungal elements
(Right) Silver stain from a phaeohyphomycotic cyst demonstrates a large fragment of woody plant matter
adjacent.
are present consistent with phaeohyphomycosis.
with proliferating fungal elements
III
1
51