Subcutaneous phycomycosis in a child

P VS Prasad, Elizabeth K Paul, Raj V George, S Ambujam, P Viswanthan

 Department of Dermatology and Pathology, Raja Muthiah Medical College & Hospital, Annamalai University, Annamalai Nagar- 608 002, India

Correspondence Address:
P VS Prasad
Department of Dermatology and Pathology, Raja Muthiah Medical College & Hospital, Annamalai University, Annamalai Nagar- 608 002
India

Introduction

Subcutaneous phycomycosis is one of the deep fungal infections caused by zygomatous species which is normally found in the tropical countries.[1] The organism responsible can be either Basidiobolus ranarum or Conidiobolus coronatus.[2],[3],[4] The basidioholus infection is seen in pediatric age group, where as conidiobolus is seen in adults[1],[2],[3],[4], The organism is found in the leaf detritus and frog dung. After inoculation into the skin, it produces a slowly spreading painless " woody" subcutaneous swelling, which is usually single. The swelling may be lobulated with rounded edges and can be raised up by inserting the fingers underneath it. The disease rarely involves the bone.[4] Oral potassium iodide is the treatment of choice.[4]

Case Report

A one and a half - year - old male child was seen with complaints of a swelling on the anterior chest wall of three months duration. On examination a nodule measuring 3 cm in diameter was noticed on the anterior chest wall, which was non - tender. A diagnosis of subcutaneous phycomycosis was made on the basis of clinical features. The swelling was completely excised. Histopathological examination confirmed the clinical diagnosis. [Figure - 1]. After one month, patient returned with a new nodule adjacent to the previous lesion measuring about 2 cm in diameter. Nodule was dull erythematous and non - tender. Lesion could be lifted up by inserting the fingers beneath it. Investigations done routinely revealed an eosinophilia (14%), others being normal. Skin biopsy was repeated which was consistent with subcutaneous phycomycosis. Organism could not be isolated in culture due to technical problems. Patient was started on syrup potassium iodide (5 drops to start with and increased to 5 drops / days). The nodule resolved completely after one month of treatment and there was no recurrence within 6 months of follow up period.

Discussion

Subcutaneous phycomycosis has typical clinical features which makes the diagnosis easier. Basidiobolomycosis occurs almost exclusively in children. The sites involved are upper part of the limbs and buttock.

Our patient presented with the lesion at the age of 1½ years. Though the diagnosis was simple, the age group and the site were unusual. The entry of the organism at the unusual site may be explained by direct injury during the child′s activities. Seven cases of subcutaneous phycomycosis in the paediatric age group were earlier described from Pondicherry.[5]

It has been reported that surgery may hasten the spread of infection.[4] The relapse of the lesion in our patient after an excisional biopsy may be explained by this. Histopathological examination is useful in confirming the diagnosis. The organism can be demonstrated histologically in the subcutaneous tissue. The main features are (1) extensive dermal and subcutaneous fibrosis (2) clusters of inflammatory cells especially eosinophils and (3) large zygomatic hyphae. The hypae appears as short sections of broad hyphae without septae, and segments often appear devoid of cytoplasm. Some may be surrounded by an eosinophilic material which is called as′ Splendore - Hoepplie′ phenomenon.[6] As when our patient was given full therapeutic doses of oral potassium iodide the lesion resolved and a follow up after six months was uneventful.

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