A healthy 58-year-old woman had a small nodular, tender, erythematous lesion on the tip of her left third toe for 2 months. The lesion was diagnosed as an abscess and was lanced. A few days later, in spite of antibiotic treatment given after a strain of Staphylococcus epidermidis was found in the wound, the clinical picture worsened: the whole toe became edematous and bluish in color. A second tender nodule, 2 cm in diameter, appeared on the back of the foot, followed by another nodule on the anterior surface of the left leg 2 weeks later. The patient was afebrile. The erythrocyte sedimentation rate was slightly elevated; the leukocyte count was high, with neutrophilia and low CD8 lymphocyte count (15%; normal range 19-39%).Physical examination revealed diffuse erythema and edema of the back of the left foot extending to the whole third toe, which was bluish with a small erosion on its back. There was a scab on the tip of the toe and under the nail (Fig. 1). Two reddish-purple, dome-shaped, rather tough nodules, 3 cm and 1 cm in diameter, respectively, were present on the back of the foot and on the anterior surface of the middle of the leg. Both were surrounded by a ring of erythematous and edematous skin (Fig. 2). Enlarged, tender lymph nodes, adherent to the deep tissues, were palpable in the left inguinocrural region. The overlying skin was erythematous.A biopsy taken from the nodule on the foot revealed the presence in the dermis of a microgranulomatous infiltrate containing eosinophils with a tendency to form microabscesses. Numerous newly formed blood vessels with hyperplasia of the endothelium and thickened walls were also present. No fungi or mycobacteria were apparent in preparations stained with the PAS and Ziehl-Neelsen methods (Fig. 3A, B).The exudate obtained from the nodule was cultured in various culture media (Sabouraud, blood-agar, selective media for mycobacteria). On Sabouraud agar a velvety white colony developed after 10 days (Fig. 4). Microscopic preparations of the colony revealed brush-like conidiophores ending in phialides carrying chains of conidia (Fig. 5) with a typical aspect of the genus Paecilomyces and very similar to Penicillium sp.
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