Case and Research Letters
Ultrasound Assessment of a Subcutaneous Eumycetoma of the Eyebrow in an Immunocompromised Patient
Evaluación ecográfica de un eumicetoma subcutáneo ciliar en una paciente inmunodeprimida
A. Combalia
, P. Giavedoni, R. Pigem, J.M. Mascaró Jr
Corresponding author
Servicio de Dermatología, Hospital Clínic de Barcelona, Barcelona, España
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Combalia, P. Giavedoni, R. Pigem, J.M. Mascaró Jr" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Combalia" "email" => array:1 [ 0 => "andreacombalia@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Giavedoni" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Pigem" ] 3 => array:2 [ "nombre" => "J.M." "apellidos" => "Mascaró Jr" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Clínic de Barcelona, Barcelona, España" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Evaluación ecográfica de un eumicetoma subcutáneo ciliar en una paciente inmunodeprimida" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1441 "Ancho" => 2000 "Tamanyo" => 533737 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Granulomas and multinucleated giant cells (hematoxylin-eosin, original magnification ×200). White arrow indicates one of the multinucleated giant cells. B, Tortuous hyphae (periodic acid-Schiff, original magnification ×400). White arrow indicates one of the hyphae. C, Tortuous hyphae (silver staining, original magnification ×200). White arrow indicates one of the hyphae.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 74-year-old Spanish woman who had a history of type 2 diabetes mellitus and high blood pressure, had undergone a kidney transplant in 2013 due to chronic renal failure secondary to diabetes, and was receiving immunosuppressant treatment with tacrolimus (1<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h), everolimus (1<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h), and prednisone (5<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h) was seen in the Dermatology Department for asymptomatic lesions on the right eyebrow that had appeared 2 months earlier and had grown progressively. The patient reported no history of trauma in the affected area. Physical examination revealed 2 painless nodules on the right eyebrow of 1<span class="elsevierStyleHsp" style=""></span>cm in diameter that were the same color as the neighboring skin and showed no signs of associated phlogosis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Skin ultrasound (MyLab 25 Gold; Esaote SpA, Genoa, Italy) in B mode using an 18-MHz probe revealed the presence in the subdermis of 2 well-delimited, rounded, hypoechoic/anechoic structures with posterior reinforcement and lateral acoustic shadowing (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). Color Doppler mode revealed an increase in perilesional flow (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D). There was no evidence of involvement of adjacent muscle or bone. Suspecting simple cysts, the lesions were excised and samples sent for pathologic examination and culture.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Hematoxylin-eosin staining revealed the presence of granulomas with a necrotic center and associated tortuous hyphae, which were visualized by periodic acid-Schiff and silver staining (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Lesion culture was positive for <span class="elsevierStyleItalic">Fusarium</span> species, and polymerase chain reaction sequencing confirmed the presence of <span class="elsevierStyleItalic">Fusarium solani</span>. Based on these findings, a diagnosis of fungal infection with secondary granulomatous reaction was established. Analysis of disease progression ruled out local invasion and associated systemic infection. Following consultation with the infection service it was decided not to administer specific systemic treatment, and complete excision of the lesions was selected as a curative treatment. After 8 months of follow-up the patient remains asymptomatic without lesion recurrence.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Mycetoma is a disease typical of tropical and subtropical regions, where it constitutes a major health problem.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> It is a locally destructive, chronic, slowly progressing and often painless infection of the skin, subcutaneous tissue, aponeurosis, muscle, and bone<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> that is difficult to diagnose and treat. It is usually caused by traumatic implantation of fungi (eumycetoma) or bacteria (actinomycetoma). Eumycetoma caused by <span class="elsevierStyleItalic">Fusarium</span> species is rare.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleItalic">F. solani</span> is a dimorphic fungus that forms chlamydospores and causes an infection in humans known as fusariosis. It is found in contaminated soil and water, and is usually inoculated into the skin of farmers or construction workers, or after accidental trauma. Infection of the face is unusual; the most commonly affected areas are the feet and/or hands.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Diagnosis is based on identification of the causative organism. This can be facilitated by the use of biopsy and/or ultrasound-guided fine-needle aspiration.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The ultrasound image of subcutaneous eumycetoma can resemble that of a simple cyst with peripheral hypervascularization, and may reveal the presence in the cyst interior of multiple hyperechoic granules,<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a> which can facilitate differential diagnosis with actinomycetoma.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The so-called dot-in-circle sign, a central hyperechoic focus (dot) within a hypoechoic area (circle), is a very specific ultrasound marker of eumycetoma in soft tissue and bone,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> although the presence of this sign is reported in very few cases in the literature. This finding has also been described in nuclear magnetic resonance images.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In our patient, skin ultrasound revealed the presence of cyst-like nodules with rich peripheral vascularization, but not the dot-in-circle sign, which could have helped establish diagnosis. It is important to include subcutaneous eumycetoma in the differential diagnosis of lesions of cystic appearance in immunocompromised patients, and to remember that skin ultrasound is a useful tool for distinguishing this lesion type from other skin lesions. In our patient, fungal inoculation may have occurred due to trauma, despite the patient's claims to the contrary.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Combalia A, Giavedoni P, Pigem R, Mascaró Jr JM. Evaluación ecográfica de un eumicetoma subcutáneo ciliar en una paciente inmunodeprimida. Actas Dermosifiliogr. 2018;109:836–838.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1500 "Ancho" => 2000 "Tamanyo" => 236731 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A and B, Two painless, skin-colored nodules of 1<span class="elsevierStyleHsp" style=""></span>cm in diameter on the right eyebrow, showing no signs of associated phlogosis. C, B-mode skin ultrasound (18-MHz probe) showing 2 well-delimited, rounded, hypoechoic/anechoic subdermal structures with posterior reinforcement and lateral acoustic shadowing. D, Color Doppler skin ultrasound (18-MHz probe) showing increased perilesional flow.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1441 "Ancho" => 2000 "Tamanyo" => 533737 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Granulomas and multinucleated giant cells (hematoxylin-eosin, original magnification ×200). White arrow indicates one of the multinucleated giant cells. B, Tortuous hyphae (periodic acid-Schiff, original magnification ×400). White arrow indicates one of the hyphae. C, Tortuous hyphae (silver staining, original magnification ×200). White arrow indicates one of the hyphae.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[Article in Spanish]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mycetoma caused by <span class="elsevierStyleItalic">Fusarium solani</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Salas-Coronas" 1 => "T. Cabezas-Fernández" 2 => "M.J. Martínez-Lage" 3 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 16 | 10 | 26 |
| 2024 October | 74 | 40 | 114 |
| 2024 September | 69 | 21 | 90 |
| 2024 August | 86 | 62 | 148 |
| 2024 July | 89 | 34 | 123 |
| 2024 June | 66 | 46 | 112 |
| 2024 May | 76 | 34 | 110 |
| 2024 April | 70 | 32 | 102 |
| 2024 March | 55 | 23 | 78 |
| 2024 February | 47 | 28 | 75 |
| 2024 January | 80 | 27 | 107 |
| 2023 December | 56 | 20 | 76 |
| 2023 November | 68 | 30 | 98 |
| 2023 October | 64 | 19 | 83 |
| 2023 September | 54 | 31 | 85 |
| 2023 August | 51 | 19 | 70 |
| 2023 July | 75 | 32 | 107 |
| 2023 June | 52 | 26 | 78 |
| 2023 May | 66 | 29 | 95 |
| 2023 April | 44 | 17 | 61 |
| 2023 March | 56 | 25 | 81 |
| 2023 February | 49 | 22 | 71 |
| 2023 January | 39 | 28 | 67 |
| 2022 December | 51 | 37 | 88 |
| 2022 November | 47 | 25 | 72 |
| 2022 October | 38 | 35 | 73 |
| 2022 September | 36 | 33 | 69 |
| 2022 August | 39 | 22 | 61 |
| 2022 July | 27 | 43 | 70 |
| 2022 June | 36 | 30 | 66 |
| 2022 May | 57 | 42 | 99 |
| 2022 April | 67 | 30 | 97 |
| 2022 March | 52 | 45 | 97 |
| 2022 February | 32 | 24 | 56 |
| 2022 January | 51 | 38 | 89 |
| 2021 December | 36 | 40 | 76 |
| 2021 November | 44 | 53 | 97 |
| 2021 October | 37 | 61 | 98 |
| 2021 September | 40 | 44 | 84 |
| 2021 August | 39 | 35 | 74 |
| 2021 July | 27 | 31 | 58 |
| 2021 June | 47 | 43 | 90 |
| 2021 May | 47 | 40 | 87 |
| 2021 April | 90 | 71 | 161 |
| 2021 March | 75 | 44 | 119 |
| 2021 February | 91 | 40 | 131 |
| 2021 January | 50 | 38 | 88 |
| 2020 December | 51 | 37 | 88 |
| 2020 November | 32 | 42 | 74 |
| 2020 October | 17 | 20 | 37 |
| 2020 September | 38 | 20 | 58 |
| 2020 August | 20 | 31 | 51 |
| 2020 July | 17 | 25 | 42 |
| 2020 June | 45 | 30 | 75 |
| 2020 May | 17 | 11 | 28 |
| 2020 April | 11 | 11 | 22 |
| 2020 March | 20 | 14 | 34 |
| 2020 February | 3 | 2 | 5 |
| 2019 August | 1 | 0 | 1 |
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