Mucocutaneous Splendore-Hoeppli phenomenon

A unique case of cutaneous tuberculosis of the scalp with extensive intracranial invasion from sub Saharan Africa

Extrapulmonary tuberculosis can present with a large variety of mimics of other, treatable, disorders. We present a young man with advanced cranial disease responding to tuberculostatic treatment but posing significant diagnostic and therapeutic challenges.

Botryomycosis: a rare mimic of sarcoma as an initial presentation of acquired immunodeficiency syndrome

Botryomycosis is a rare granulomatous response to chronic bacterial infection most frequently associated with Staphylococcus aureus. This disease, which predominantly affects immunocompromised patients, may present with cutaneous, visceral, or soft tissue manifestations. Soft tissue involvement typically has an aggressive mass-like appearance on imaging which can be concerning for malignancy. In immunocompromised patients, botryomycosis can resemble fungal infection both clinically and histologically; therefore, definitive diagnosis requires tissue sampling along with histological and microbiological analysis. Presented here is a 25-year-old man with an enlarging intramuscular soft tissue mass of the right forearm as his first presentation of undiagnosed acquired immunodeficiency syndrome (AIDS). MR imaging showed a mildly T2 hyperintense and enhancing mass with infiltrative margins extending through tissue planes. Biopsy of the mass revealed Staphylococcus aureus-associated botryomycosis, which improved with nonsurgical treatment employing antibiotics. Unfortunately, the patient subsequently expired from other manifestations of his new AIDS diagnosis. This case describes the MR and PET-CT appearance of botryomycosis and also underscores that infection can mimic sarcoma, particularly in the setting of immunodeficiency.

Navigating Challenges in Cervicofacial Actinomycosis: A Case of Diagnostic Persistence and Multidisciplinary Collaboration

Actinomycosis is a rare, chronic bacterial infection caused by Actinomyces species, characterized by granulomatous inflammation, abscesses, and sinus tracts. It primarily affects the cervicofacial region and often mimics other conditions such as malignancies or tuberculosis, complicating early diagnosis and treatment. This case report details an 18-year-old male with no known comorbidities, who presented with a two-week history of facial swelling, trismus, and discharging fistulas following an insect bite. The delay in seeking medical attention was due to initial symptom subsidence and challenges in accessing care. Diagnostic difficulties arose from inconclusive pus cultures and the lack of specialist resources at our facility. An incisional biopsy and subsequent histopathological examination revealed basophilic Gram-positive, non-acid fast filamentous bacteria and the Splendore-Hoeppli phenomenon, ultimately confirming actinomycosis. This case highlights the necessity of including actinomycosis in the differential diagnosis of facial infections and demonstrates the value of a multidisciplinary approach in managing complex cases with diagnostic and therapeutic challenges.

Microsporum canis Causes Cutaneous and Extracutaneous Feline Dermatophytic Pseudomycetomas: Molecular Identification and Clinicopathological Characteristics

Dermatophytic pseudomycetoma (DPM) is a rarely reported invasive fungal infection of humans and animals, especially cats. This study aimed to identify dermatophytes, breed associations, and the frequency of extracutaneous (EC) involvement in feline DPM. Electronic records and formalin-fixed paraffin-embedded tissue (FFPET) from 32 suspected DPM cases in 30 cats were retrieved from a diagnostic laboratory between 2018 and 2024. To confirm DPM and molecular identity, DNA was extracted from FFPET for ITS2 sequencing, and immunohistochemistry was performed on PCR-negative cases. All cases were confirmed as DPM. Microsporum canis was the only dermatophyte identified. The sensitivity and specificity of ITS2 sequencing for M. canis identification in FFPET were 22/32 (68.8%) and 21/22 (95.5%), respectively. Exotic (36.7%) and Persian (23.3%) but not British breeds (26.3%) were over-represented compared to feline admissions at an affiliated veterinary hospital (8.5%, p < 0.001; 3%, p < 0.001; 21.6%, p = 0.817, respectively). Five cases (16.7%) had EC lesions; two had intra-abdominal masses; two had oral cavity masses, including one which extended into the cranial vault; and one had superficial cervical lymph node invasion. Exotic and Persian breeds are over-represented for DPM and M. canis is the primary cause. EC lesions of DPM may occur more commonly than previously thought.

MALDI TIMS IMS Reveals Ganglioside Molecular Diversity within Murine S. aureus Kidney Tissue Abscesses

Gangliosides play important roles in innate and adaptive immunity. The high degree of structural heterogeneity results in significant variability in ganglioside expression patterns and greatly complicates linking structure and function. Structural characterization at the site of infection is essential in elucidating host ganglioside function in response to invading pathogens, such as Staphylococcus aureus (S. aureus). Matrix-assisted laser desorption/ionization imaging mass spectrometry (MALDI IMS) enables high-specificity spatial investigation of intact gangliosides. Here, ganglioside structural and spatial heterogeneity within an S. aureus-infected mouse kidney abscess was characterized. Differences in spatial distributions were observed for gangliosides of different classes and those that differ in ceramide chain composition and oligosaccharide-bound sialic acid. Furthermore, integrating trapped ion mobility spectrometry (TIMS) allowed for the gas-phase separation and visualization of monosialylated ganglioside isomers that differ in sialic acid type and position. The isomers differ in spatial distributions within the host-pathogen interface, where molecular patterns revealed new molecular zones in the abscess previously unidentified by traditional histology.

Importance of clinico-pathologic correlation in rare, chronic infectious diseases: Actinomycetoma misdiagnosed as botryomycosis-A case report

This case report explores the clinical journey of a patient initially diagnosed with botryomycosis, only to later reveal the underlying and rare condition of actinomycosis. The report highlights the challenges in getting to an accurate diagnosis, emphasizing the importance of considering uncommon pathologies, the utility of multi-disciplinary teams and clinico-pathologic correlation in clinical practice.

Pulmonary lesions with asteroid bodies in a pig experimentally infected with Actinobacillus pleuropneumoniae serovar 15

Five pigs experimentally infected with Actinobacillus pleuropneumoniae serovar 15 isolated in our previous study were pathologically examined. One pig died at 2 days post inoculation (dpi) and four pigs were euthanized at 7 dpi. Autopsy revealed fibrinohemorrhagic pleuropneumonia in all pigs. Histopathologically, the lesions were characterized by extensive hemorrhage and necrosis, fibrin deposition, and multifocal abscesses composed of numerous neutrophils including oat cells and numerous Gram-negative bacilli. In one survived pig, asteroid body formation was confirmed in the lung. The bacteria within the abscesses and asteroid bodies were immunohistochemically positive for antiserum raised against A. pleuropneumoniae serovar 15. This is the first report describing porcine pleuropneumonia with asteroid bodies in a pig experimentally infected with A. pleuropneumoniae serovar 15.

Gastrointestinal mucormycosis following liver transplantation: lessons learnt

Gastrointestinal mucormycosis (GIM) is an uncommonly encountered fungal infection following solid-organ transplantation. GIM is known to be associated with immunocompromised states, remains difficult to diagnose and often results in fatal outcomes. It is plausibly the delay in initiation of appropriate treatment strategies that leads to failure of response and patient demise. We report two cases of GIM following live donor liver transplantation, presenting with bleeding and perforation, respectively, highlighting the challenges in making a timely diagnosis of mucormycosis, particularly in immunocompromised patients.

Primary pulmonary botryomycosis. Report of a case and literature review

Botryomycosis is a rare chronic suppurative infection characterised by a granulomatous inflammatory response to bacterial pathogens. Among the two forms, the visceral form is an even rarer finding that mainly affects the lungs and whose main causative agents are Staphylococcus aureus and Pseudomonas aeruginosa, although many other non-filamentous bacteria have been identified. Here, we present a case of primary pulmonary botryomycosis, which to our knowledge is the first case of this type reported in Mexico. In addition, we review the 18 cases of primary pulmonary botryomycosis reported in the literature, where we focus on evaluating the clinical characteristics, predisposing factors, causative agents and treatments used in these patients. This helps physicians to improve the differential diagnosis of this disease.

Infection Due to Actinobacillus lignieresii in Cattle with Brain and Ocular Involvement: Histological and Microbiological Features

The actinobacillosis is rare and to date the biological profile of the agent is not yet fully understood. The knowledge about the possible hosts of the pathogen is incomplete and is generally only associated with granulomatous lesions in cattle and sheep. The primary organs involved are the mouth, tongue and pharynx. Human infection is extremely rare. Actinobacillus lignieresii is the causative agent of a rare bovine granulomatous disease known as "wooden tongue". In this research, we describe a case of cerebral and ocular metastatic diffusion of granuloma due to infection with Actinobacillus lignieresii in cattle, probably resulting from primary oral localization. Diagnosis was made using histopathological assay which made it possible to highlight the typical lesion of actinobacillosis, and bacteriological assay that allowed to isolate the pathogen.

Schistosomiasis Mansoni-Recruited Eosinophils: An Overview in the Granuloma Context

Eosinophils are remarkably recruited during schistosomiasis mansoni, one of the most common parasitic diseases worldwide. These cells actively migrate and accumulate at sites of granulomatous inflammation termed granulomas, the main pathological feature of this disease. Eosinophils colonize granulomas as a robust cell population and establish complex interactions with other immune cells and with the granuloma microenvironment. Eosinophils are the most abundant cells in granulomas induced by Schistosoma mansoni infection, but their functions during this disease remain unclear and even controversial. Here, we explore the current information on eosinophils as components of Schistosoma mansoni granulomas in both humans and natural and experimental models and their potential significance as central cells triggered by this infection.

Current Progress on Epidemiology, Diagnosis, and Treatment of Sporotrichosis and Their Future Trends

Sporotrichosis, a human and animal disease caused by Sporothrix species, is the most important implantation mycosis worldwide. Sporothrix taxonomy has improved in recent years, allowing important advances in diagnosis, epidemiology, and treatment. Molecular epidemiology reveals that S. brasiliensis remains highly prevalent during the cat-transmitted sporotrichosis outbreaks in South America and that the spread of S. brasiliensis occurs through founder effects. Sporothrix globosa and S. schenckii are cosmopolitan on the move, causing major sapronoses in Asia and the Americas, respectively. In this emerging scenario, one-health approaches are required to develop a creative, effective, and sustainable response to tackle the spread of sporotrichosis. In the 21st century, it has become vital to speciate Sporothrix, and PCR is the main pillar of molecular diagnosis, aiming at the detection of the pathogen DNA from clinical samples through multiplex assays, whose sensitivity reaches remarkably three copies of the target. The treatment of sporotrichosis can be challenging, especially after the emergence of resistance to azoles and polyenes. Alternative drugs arising from discoveries or repositioning have entered the radar of basic research over the last decade and point to several molecules with antifungal potential, especially the hydrazone derivatives with great in vitro and in vivo activities. There are many promising developments for the near future, and in this review, we discuss how these trends can be applied to the Sporothrix-sporotrichosis system to mitigate the advance of an emerging and re-emerging disease.

Reinhard Hoeppli (1893-1973): The life and curious afterlife of a distinguished parasitologist

Reinhard Hoeepli was a Swiss-German physician with a distinguished career as a researcher and historian of medical parasitology. He spent the majority of his career at the Peking Union Medical College in Beijing, China, where he undertook research on host responses to parasitic infections, in particular describing the 'Splendore-Hoeppli phenomenon', between 1929 and 1952. During the Second World War, he acted as the Swiss honorary Consul in Japanese-occupied Beijing. After leaving China following the militarization of the College in the wake of the Korean War, he subsequently worked in Singapore and Liberia before retiring to Switzerland. Hoeppli is most widely known for his association with Sir Edmund Backhouse, a controversial and enigmatic Chinese scholar, who was his war-time patient towards the end of his life. With Hoeppli's encouragement, Backhouse wrote two scandalous and unpublishable memoirs which remained in Hoeppli's safe-keeping until his own death in 1973. However, the revelations by the historian Hugh Trevor-Roper in 1976 that Backhouse was a fraudster and fantasist has had a detrimental effect on Hoeppli's posthumous reputation that has overshadowed his many lifetime achievements. Alongside a biography of his life, an examination of the controversies of the Backhouse revelations on Hoeppli's repute is presented.

An 18-year-old man with tropical verrucous syndrome: Leishmaniasis or sporotrichosis?

El síndrome verrugoso tropical comprende condiciones cutáneas infecciosas, crónicas y granulomatosas que cursan con placas, nódulos o úlceras verrugosas, de ahí su nombre. Este síndrome incluye la cromoblastomicosis, la esporotricosis, la paracoccidioidomicosis, la lobomicosis, la leishmaniasis y la tuberculosis cutánea verrugosa, todas ellas enfermedades de amplia distribución en áreas tropicales y subtropicales.

Sus diagnósticos pueden ser difíciles y confundirse entre sí, lo cual es más frecuente entre la esporotricosis y la leishmaniasis. Para distinguirlas se recurre a criterios clínicos y epidemiológicos, y a métodos diagnósticos como intradermorreacción, examen directo, biopsia, cultivo, inmunofluorescencia y PCR, algunos de los cuales no son de uso común. El diagnóstico preciso conduce al tratamiento adecuado.

Se presenta el caso de un hombre de 18 años con extensas placas verrugosas en una rodilla, inicialmente interpretadas como leishmaniasis verrugosa por la clínica, la epidemiología y la biopsia. Se le trató con Glucantime® durante 20 días, pero no presentó mejoría, por lo que se tomó una nueva biopsia que también se interpretó como leishmaniasis cutánea. La revisión de ambas biopsias evidenció inflamación con granulomas abscedados y presencia de cuerpos asteroides esporotricósicos, que condujeron al diagnóstico de esporotricosis, el cual se confirmó luego con el cultivo del hongo. Las lesiones remitieron con la administración de itraconazol.

La clínica y la epidemiología de la leishmaniasis y las de la esporotricosis pueden ser semejantes, por lo que la biopsia y los estudios de laboratorio son esenciales para establecer el diagnóstico. El cuerpo asteroide esporotricósico es patognomónico de esta entidad. Se revisaron los conceptos esenciales de estas condiciones y los criterios para diferenciarlas.

Cutaneous botryomycosis in a free-living short-beaked echidna (Tachyglossus aculeatus)

Botryomycosis is a chronic bacterial infection of the skin and viscera caused by nonbranching bacteria such as Staphylococcus spp. It results in the formation of chronic, suppurative and often granulomatous lesions that may resemble multiple abscesses. It has been diagnosed worldwide in both humans and animals. It is a rare disease, usually requiring surgical excision combined with long-term antibiotics to achieve a good resolution. A wild echidna (Tachyglossus aculeatus) was presented with a soft tissue mass at the base of the right distal beak with multiple discharging fistulas arising from it. The mandible appeared to be shortened and deviated to the right, and the animal was unable to close its beak. The echidna was in poor body condition and was euthanased on welfare grounds. Histopathology of the lesions demonstrated the classical botryoid lesions with the characteristic Splendore-Hoeppli reaction surrounding the bacterial colonies, in a background of extensive granulation tissue. Radiographs revealed mild mandibular osteomyelitis, yet haematology and biochemistry results were nonspecific. This disease has not previously been reported in a wild monotreme.

Eumycetoma of the Foot due to Fusarium solani in a Person with Diabetes Mellitus: Report of a Case and Review of Literature

Eumycetomas are chronic suppurative granulomas caused by fungi characterised by invasive tumefactive lesions, sinuses and discharging grains. Herein, we describe a case of pedal eumycetoma due to Fusarium solani sensu stricto in a person with diabetes mellitus. A 45-year-old gentleman presented with an insidious onset swelling over his right foot with nodules and discharging grains. He had received itraconazole and anti-tuberculous therapy elsewhere, without response. Re-evaluation included a biopsy which confirmed eumycetoma and newly diagnosed diabetes. Surgical excision followed by histopathological, microbiological and multigene sequencing analyses [translation elongation factor, calmodulin and internal transcribed spacer region of rDNA] of the mould on culture were performed. Histopathology revealed septate fungal hyphae amidst a dense inflammatory infiltrate (Splendore-Hoeppli) reaction. Oral voriconazole was started and good glycemic control attained. Tissue growth sequences showed > 99% similarity with Fusarium solani sensu stricto. Antifungal susceptibility testing showed lowest MIC to voriconazole (0.5 mg/L). The patient showed excellent response to combined therapeutic modality with a near-complete resolution in size of lesion and obliteration of sinuses following 4 months of therapy and is planned for prolonged voriconazole therapy till complete radiological resolution. Diabetes predisposes to fungal infections of foot but eumycetomas are uncommon. Combined surgery and antifungals can improve morbidity and avoid amputations.

Novel Pulmonary Vasculitis with Splendore-Hoeppli Reaction in Grey Seals (Halichoerus grypus) Associated with Otostrongylus circumlitus Infection

Lungworm infection in seals is an important cause of morbidity and mortality, inducing bronchopneumonia and affecting population dynamics in some areas of the world. We present a series of cases of lungworm infection in grey seals (Halichoerus grypus) associated with novel, significant and unusual pulmonary vascular changes. Grey seals (n = 180) that were stranded, in rehabilitation or in long-term captivity in the UK were subjected to post-mortem examination between 2012 and 2018. Lung tissue was collected from 47 individuals for histopathological examination. Polymerase chain reaction (PCR) on formalin-fixed and paraffin wax-embedded (FFPE) material was attempted for parasite identification on selected sections using lungworm-specific primers, and nematode morphology within sections was evaluated histologically. Fourteen of 47 (30%) of these grey seals showed evidence of segmental granulomatous and eosinophilic vasculitis with an intramural Splendore-Hoeppli reaction in medium to large pulmonary arteries. Intravascular nematodes suggestive of Otostrongylus circumlitus were seen in two cases. PCR on FFPE material was unable to detect a signal on selected tissue sections. Of the 14 affected seals, nine had concurrent bronchopneumonia and four had intra-alveolar/bronchiolar Parafilaroides spp. Thirteen of 14 animals with vasculitis lesions were weaned pups with only one adult affected. Previous pathological descriptions of lungworm infection in grey seals have dealt mainly with the bronchopneumonia. This case series has identified previously unrecorded vascular changes characterized by an intramural Splendore-Hoeppli reaction. Such change would impact on vascular integrity, increasing the likelihood of vascular rupture with pulmonary haemorrhage and increased risk of intravascular coagulation. A host-parasite relationship with the persistence of antigenic material following close contact with, or migration through, the blood vessel wall is suspected.

Balloons and Stents and Scaffolds: Preclinical Evaluation of Interventional Devices for Occlusive Arterial Disease

Atherosclerosis places a significant burden on humankind; it is the leading cause of mortality globally, and for those living with atherosclerosis, it can significantly impact quality of life. Fortunately, treatment advances have effectively reduced the morbidity and mortality related to atherosclerosis, with one such modality being percutaneous intervention (PCI) to open occluded arteries. Over the 40-year history of PCI, preclinical models have played a critical role in demonstrating proof of concept, characterizing the in vivo behavior (pharmacokinetics, degradation) and providing a reasonable assurance of biologic safety of interventional devices before entering into clinical trials. Further, preclinical models may provide insight into the potential efficacy of these devices with the appropriate study design and end points. While several species have been used in the evaluation of interventional devices, the porcine model has been the principal model used in the evaluation of safety of devices for both coronary and endovascular treatments. This article reviews the fundamentals of permanent stents, transient scaffolds, and drug-coated balloons and the models, objectives, and methods used in their preclinical evaluation.

Atypical actinobacillosis affecting hind limbs and lungs in a single beef cattle herd

Actinobacillosis usually is a sporadic infection that affects the tongue in cattle (“wooden tongue”) with possible spread to the digestive tract. Two 4‐year‐old Rouge‐des‐Prés cows from a single French beef herd were referred for chronic (2‐6 months) swelling and cutaneous nodules in the distal hind limbs. In addition to cutaneous signs, physical examination disclosed cachexia, lameness, lymphadenitis of the hind limbs, and pneumonia in both cows. Cytologic examination of direct skin smears was inconclusive, and no parasites were observed in examination of multiple skin scrapings. Histopathological examination of skin and lung biopsy specimens identified chronic, diffuse, severe pyogranulomatous dermatitis, associated with Splendore‐Hoeppli phenomenon and intralesional Gram‐negative bacteria. Cultures from skin, lymph nodes, and lungs (both cows were euthanized for welfare reasons) identified a Pasteurellaceae organism, confirmed as Actinobacillus lignieresii by partial sequencing of the rpoB gene. This report emphasizes that actinobacillosis can appear as a small outbreak in cattle with cutaneous and respiratory signs.

Disseminated angioinvasive basidiobolomycosis with a favourable outcome

Basidiobolomycosis, a rare fungal infection, is of worldwide distribution but areas commonly involved include the tropical areas of Africa, USA and South East Asia. 88% of the cases are reported among patients younger than 20 years. Many of the case reports in Saudi Arabia are from Tohama area where our patient lives. The diagnosis tends to be overlooked as the presentation may mimic colonic carcinoma in adults or inflammatory bowel diseases and tuberculosis in both children and adults. Angioinvasion seen in our patient is extremely rare suggesting the diagnosis of mucormycosis and resulting in a delay in choosing the most appropriate treatment. We report this case to remind physicians and surgeons to consider this diagnosis in patients from endemic area presenting with such conditions.

Human Pathogenic Entomophthorales

The pathogenic entomophthoralean fungi cause infection in insects and mammalian hosts. Basidiobolus and Conidiobolus species can be found in soil and insect, reptile, and amphibian droppings in tropical and subtropical areas. The life cycles of these fungi occur in these environments where infecting sticky conidia are developed. The infection is acquired by insect bite or contact with contaminated environments through open skin. Conidiobolus coronatus typically causes chronic rhinofacial disease in immunocompetent hosts, whereas some Conidiobolus species can be found in immunocompromised patients. Basidiobolus ranarum infection is restricted to subcutaneous tissues but may be involved in intestinal and disseminated infections. Its early diagnosis remains challenging due to clinical similarities to other intestinal diseases. Infected tissues characteristically display eosinophilic granulomas with the Splendore-Höeppli phenomenon. However, in immunocompromised patients, the above-mentioned inflammatory reaction is absent. Laboratory diagnosis includes wet mount, culture serological assays, and molecular methodologies. The management of entomophthoralean fungi relies on traditional antifungal therapies, such as potassium iodide (KI), amphotericin B, itraconazole, and ketoconazole, and surgery. These species are intrinsically resistant to some antifungals, prompting physicians to experiment with combinations of therapies. Research is needed to investigate the immunology of entomophthoralean fungi in infected hosts. The absence of an animal model and lack of funding severely limit research on these fungi.

Microbiological Profile of Chronic Tonsillitis in the Pediatric Age Group

Introduction

Tonsillitis is a very common disease in children. Understanding the microbiology and pathology of chronic tonsillitis is an important step in its management. The aim of the study was to describe the microbiological profile of core tonsillar tissue in chronic tonsillitis in children.

Materials and methods

Children under 16 years of age with chronic tonsillitis were recruited in the descriptive study. Children with recurrent tonsillitis and recurrent tonsillitis with obstructive symptoms were included. Children who underwent tonsillectomy for obstructive symptoms alone and those who received antibiotics for at least one month prior to surgery were excluded from the study. Dissection and the snare method of tonsillectomy were done on all children. The operated specimen was cut into two halves in a sterile container. The core of the tonsillar tissue was swabbed with two sterile cotton-tipped swabs and sent for the microbiological evaluation of aerobes and anaerobes. The tonsillar tissue was sent for a histopathological examination.

Results

A total of 106 children were operated for chronic tonsillitis in one year. The mean age of children included in this study was 9.4 years. The duration of symptoms due to tonsillar disease ranged from four weeks to 28 months. There were 48 males and 58 females. Recurrent tonsillitis was the most common indication for tonsillectomy in all children. A total of 301 aerobes and 171 anaerobic microorganisms were isolated from 106 children with chronic tonsillitis. The aerobic bacterial species most often isolated was Streptococcus viridans, which was present in 83 children followed by Group A, β-hemolytic Streptococci in 67 children. The anaerobic bacterial most often isolated was Peptococcus species in 49 children. Polymicrobial aerobic and anaerobic flora were present in all tonsillar specimens, yielding an average of 4.1 isolates per specimen. The histopathological examination revealed chronic tonsillitis with reactive follicular hyperplasia in all (100%) children. Actinomycosis was associated with non-specific reactive follicular hyperplasia in four specimens.

Conclusion

Polymicrobial aerobic and anaerobic flora are identified in deep tonsillar tissue in children with tonsillitis. The identification of bacterial isolates from the core tissue in recurrent tonsillitis could dictate the management of chronic tonsillitis. The histopathological examination of the core tissues of the tonsils helps in an accurate identification of organisms that are difficult to culture.

Local extensive granulomatous inflammation of the neck region and lymphangitis caused by Lichtheimia corymbifera infection in a Japanese Black calf

A 7-month-old female Japanese Black calf developed elongated, nodular mass measuring 30 × 16 cm extended from the retropharyngeal region to mid lateral neck region. Histological examination revealed granulomatous lymphangitis with non-septate fungal hyphae recognized throughout the lesions. Fungal culture, DNA sequencing and molecular phylogenetic tree analysis confirmed the sequence of Lichtheimia corymbifera. The lymphogenous route was speculated to be the main route of fungal spread leading to the characteristic nodular appearance of this case.

Lomentospora prolificans vertebral osteomyelitis with spinal epidural abscess in an immunocompetent woman: Case report and literature review

Lomentospora prolificans is a rare cause of vertebral osteomyelitis. We report a case of L. prolificans thoracic vertebral osteomyelitis with spinal epidural abscess in a patient without apparent immunodeficiency. Clinical manifestations and radiographic findings could not distinguish from other etiologic agents. Treatment is also challenging because L. prolificans is usually resistant to antifungal agents. The patient underwent surgical debridement and has been receiving a prolonged combination of antifungal therapy to prevent an infection relapse.

Subcutaneous Granulomatous Inflammation due to Basidiobolomycosis: Case Reports of 3 Patients in Buruli Ulcer Endemic Areas in Benin

BACKGROUND

Basidiobolomycosis is a rare subcutaneous mycosis, which can be mistaken for several other diseases, such as soft tissue tumors, lymphoma, or Buruli ulcer in the preulcerative stage. Microbiological confirmation by PCR for Basidiobolus ranarum and culture yield the most specific diagnosis, yet they are not widely available in endemic areas and with varying sensitivity. A combination of histopathological findings, namely, granulomatous inflammation with giant cells, septate hyphal fragments, and the Splendore-Hoeppli phenomenon, can confirm basidiobolomycosis in patients presenting with painless, hard induration of soft tissue.

CASE PRESENTATIONS

We report on three patients misdiagnosed as suffering from Buruli ulcer, who did not respond to Buruli treatment. Histopathological review of the tissue sections from these patients suggests basidiobolomycosis. All patients had been lost to follow-up, and none received antifungal therapy. On visiting the patients at their homes, two were reported to have died of unknown causes. The third patient was found alive and well and had experienced local spontaneous healing.

CONCLUSION

Basidiobolomycosis is a rare subcutaneous fungal disease mimicking preulcerative Buruli ulcer. We stress the importance of the early recognition by clinicians and pathologists of this treatable disease, so patients can timely receive antifungal therapy.

Entomophthoromycosis and mucormycosis as causes of pneumonia in Vietnamese potbellied pigs

Two Vietnamese potbellied pigs ( Sus scrofa) had respiratory disease and, on autopsy, both pigs had large masses in the lungs and thoracic cavity. Microscopically, pulmonary and pleural masses contained large areas with hyphae surrounded by hypereosinophilic cellular debris rimmed by abundant eosinophils, lymphocytes, plasma cells, and histiocytes with occasional multinucleate giant cells. The hypereosinophilic debris usually formed tight cuffs, or "sleeves" around the hyphae, compatible with Splendore-Hoeppli-like material. The fungal organisms were determined by PCR to be Conidiobolus incongruus in one pig and Mucor circinelloides in the other. Entomophthoromycosis and mucormycosis should be included in the differential diagnoses for swine pneumonia, particularly when there is evidence of granulomatous pulmonary masses and pleural effusion with eosinophilic inflammation.

Primary photosensitization and contact dermatitis caused by Malachra fasciata Jacq. N.V. (Malvaceae) in sheep

Farmers from Paraiba state, Northeast Brazil, claim that Malachra fasciata causes cutaneous lesions in sheep. To test its toxicity the plant was harvested daily and fed ad libitum for 21 days to 3 sheep as the sole food source (# 1-3). An additional sheep (# 4) was maintained as a control. Cutaneous lesions of photosensitization initiated after 7 days and increased continuously over the next 21 days. The dose ingested varied between 129 g/kg to 175 g/kg. Alopecia, hyperemia and crusting were observed in the animals. On day 22, sheep 3 was euthanized. At necropsy, no gross or microscopic alterations were observed in the liver. Skin biopsies were performed in the remaining animals Histopathology of skin of the three sheep included acanthosis, orthokeratosis, and multifocal infiltration by lymphocytes, eosinophils and plasma cells around blood vessels and appendages in the dermis. The Splendore-Hoeppli phenomenon was observed in the dermis of sheep 2, due probably by contact dermatitis. After the end of administration Sheep 1 and 2 were protected from sunlight and the lesions regressed within two weeks. This experiment indicates that M. fasciata causes primary photosensitization and contact dermatitis in sheep.

The cytopathology of Actinomyces, Nocardia, and their mimickers

Nocardia species and Actinomyces species are 2 of the most commonly diagnosed filamentous bacteria in routine cytopathology practice. These genera share many overlapping cytomorphologic features, including their thin, beaded, branching, Gram-positive, GMS-positive filamentous structures that fragment at their peripheries into bacillary- and coccoid-appearing forms. Features that help distinguish between these 2 microorganisms include the width of their filamentous structures, the angles at which they branch, and their ability or lack thereof to retain a modified acid-fast stain. In addition to cytomorphologic overlap, overlap in clinical presentation is frequent with pulmonary and mucocutaneous presentations seen in both. Differentiating between Nocardia and Actinomyces is essential because patients with these infections require different approaches to medical management. Both antibiotic susceptibilities and the need for early surgical intervention as part of the treatment plan vary greatly among these 2 groups. This review focuses on the clinical presentation, cytomorphology and staining characteristics that can be useful in identifying and distinguishing between Nocardia and Actinomyces infections, as well as their mimickers.

Cytopathology of Hepatobiliary-Related Actinomycosis

BACKGROUND

The clinical diagnosis of hepatobiliary-related actinomycosis can be challenging owing to its rarity and variable presentation. Moreover, actinomycotic pseudotumors may mimic malignancy and result in unnecessary surgical resection. Herein, we present the clinical and cytopathological features of 3 cases with hepatobiliary-related actinomycosis.

CASES

The first patient was a 73-year-old man who presented with an exophytic liver lesion. The second patient was a 78-year-old woman who presented with a biliary stricture. The third patient was an 88-year-old woman with a right flank mass extending to the liver. The aspirate smears in these 3 cases demonstrated 'cotton ball' clusters of filamentous microorganisms and abscesses. The cell blocks of 2 of the patients showed sulfur granules with peripheral filamentous microorganisms positive with a Gram stain but negative with an acid fast stain, consistent with Actinomyces species. All patients were elderly and shared a past surgical history of laparoscopic cholecystectomy.

CONCLUSION

These cases demonstrate the complementary role of cytology in the diagnosis of hepatobiliary actinomycosis. A cytologic diagnosis of actinomycosis is minimally invasive and quick. It can prompt proper culture medium selection and avoid unnecessary or extensive surgery. Based on our experience, laparoscopic cholecystectomy may be a precipitating factor for the subsequent development of hepatobiliary-related actinomycosis.

Entomophthoramycosis: a neglected tropical mycosis

The term 'entomophthoramycosis' classically refers to infections caused by members of the order Entomophthorales. A new subphylum, Entomophthoramycota, has been created to include Basidiobolomycetes, Neozygitomycetes and Entomophthoramycetes. Basidiobolomycetes encompass Basidiobolus spp., while the Entomophthoramycetes include Conidiobolus spp. Conidiobolus spp. characteristically cause rhinofacial entomophthoramycosis in apparently immunocompetent hosts. Conidiobolus spp. may also cause disseminated infection in immunocompromised patients. Basidiobolus spp. more typically cause subcutaneous entomophthoramycosis of the limbs, buttocks, back and thorax in immunocompetent patients. While once considered to be rare, there is an increasing number of reported cases of gastrointestinal infection caused by Basidiobolus spp. worldwide in countries such as United States, Thailand, Australia, Iran, Egypt and Saudi Arabia. These cases have clinical presentations similar to those of inflammatory bowel diseases, particularly Crohn's disease. Retroperitoneal, pulmonary, nasal and disseminated basidiobolomycosis have also been reported. Histology of entomophthoramycosis may reveal the Splendore-Hoeppli phenomenon. Culture of infected tissue remains the definitive method of laboratory diagnosis. However, molecular methods with specific DNA probes and panfungal primers, as well as real time PCR, are increasingly used to detect and identify these organisms in tissue. Treatment largely consists of therapy with antifungal triazoles. Surgery plays a selective role in the management of entomophthoramycosis, depending upon location, organism and extent of the infection.