Cutaneous phaeohyphomycosis caused by Exophiala jeanselmei

A 72-year-old man with a history of resected carcinoma who had been administered 5-fiuorouracil (100 mg/d) orally, was being treated with corticosteroid (PSL 18 mg/d) and cyclosporine A (50 mg/d) for recalcitrant bullous pemphigoid, when he became aware of swelling on his left hand. At a consultation in January 2009, he was found to have a slightly raised brown-red swelling extending from the dorsal aspect of the left hand to the 3rd and 4th fingers, with soft nodules. Some of the nodules were asymptomatic, soft, edematous, and partially encrusted, and discharged purulent exudates upon application of pressure. There was no local warmth. On histopathological sections, dense neutrophilic and histiocytic infiltration was observed in the middle dermis, and chains of sporelike fungal elements were observed scattered throughout the lesion on PAS and Grocott staining. Fungal cultivation from the crust of one nodule and discharge from a biopsy specimen demonstrated the organism to be a black mold. Both of these isolates were compatible with Exophiala jeanselmei on morphological findings and DNA sequence of the internal transcribed spacer regions of the ribosomal DNA. The patient was successfully treated with oral terbinafine (125 mg/d) combined with local hyperthermia over the course of 1 month.