An 87-year-old man, a gardener in Okinawa, first noticed a
tumor on the dorsum of his right hand in November 2005. He had been taking
prednisolone for the treatment of
polymyalgia rheumatica since 2000. A nearby dermatologist incised the
tumor for
pus drainage in February 2006. In April of the same year, the dome-like
tumor reappeared. The same treatment was repeated. Because the culture of the
pus revealed fungi at that time,
terbinafine hydrochloride and
minocycline were administrated under the diagnosis of a deep
fungal infection. After a short remission, the
tumor recurred in November of the same year and in May and August of 2007 regardless of the repeated incision and
pus drainage. He was referred to our hospital on 27 September 2007. His first physical examination at our outpatient office showed a skin-colored, well-demarcated, multilocular, cystic subcutaneous
tumor on the dorsum of his right hand. Histopathological examination revealed a pseudocyst with fibrous walls of connective tissue. Continuous, bead-like hyphae, positive with
periodic acid-Schiff
stain and Grocott
stain, were found within the pseudocyst. Morphological and molecular
biological examinations of the separately cultured specimens identified the causative agent as Exophiala jeanselmei. The entire
cyst was removed under
local anesthesia, and an artificial dermis made of
silicon membrane was applied to the
wound. Skin graft was performed in November after confirming no recurrence of the
fungal infection.
Terbinafine hydrochloride 125 mg/day has continued. No recurrence has been observed up to now.