Pheohyphomycosis: A curious case of cyst
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Many fungi causing human disease may be melanized and are known as “dematiaceous fungi.” Pheoid fungi may cause clinical syndromes ranging from insidious cutaneous disease to life-threatening infections involving the central nervous system. When these fungi cause subcutaneous infections, it is known as pheohyphomycosis. Exophiala spinifera is a rare cause of cutaneous infection manifesting as pheohyphomycosis or chromoblastomycosis .

A 15-year-old girl presented with a 5-month history of multiple, asymptomatic, skin-colored cysts over both sides of the neck along the sternocleidomastoid simulating enlarged lymph nodes. The cysts were multiple but discrete, with diameter ranging from 2 to 4 cm. The largest cyst present over the left scapula measured 10 × 8 cm in size and was non-tender, fluctuant and negative on transillumination. On the back there were multiple discrete to coalescent, oval, hypertrophic scars, some atrophic areas and some sites of depigmentation at the site of previously healed lesions. On a clinical suspicion of deep fungal infection, oral itraconazole 200 mg per day for 6 months were given with significant improvement, after which the treatment was stopped. Skin biopsy showed a granulomatous inflammation in the dermis.

The patient was given itraconazole 100 mg twice a day the larger cyst was aspirated and a drain kept in situ for 3 days. The patient has received 8 months of itraconazole with marked improvement. It was planned to continue itraconazole 200 mg a day for 18–24 months.

The presence of melanin in the hyphal cell wall gives it the name “black mold.” E. spinifera may clinically present both as pheohyphomycosis as well as chromoblastomycosis. The distinguishing feature between the two is the presence of “Medlar” or copper penny bodies on histopathology in chromoblastomycosis. The extensive and recurrent disease with multiple cysts, predominantly truncal involvement in a healthy young girl is, thus, a rare and noteworthy presentation of these uncommon mycoses.