deep fungal and higher bacterial skin infections in thailand: clinical manifestations and treatment...

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Report Deep fungal and higher bacterial skin infections in Thailand: clinical manifestations and treatment regimens Punkae Mahaisavariya, MD, Angkana Chaiprasert, Dr.rer.nat., Apichati Sivayathorn, MD, and Supakan Khemngern, MABS From the Departments of Abstract Dermatology and Microbiology, Background Deep fungal and higher bacterial skin infections occur fairly frequently in Faculty of Medicine, Siriraj Hospital, Thailand. Mahidol University, Bangkok, Thailand Methods Cases with a provisional diagnosis of deep fungal and higher bacterial infections were prospectively collected from 1994 to 1997 in the Granuloma Clinic, Correspondence Punkae Mahaisavariya, MD Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Siriraj Hospital, 2 Prannok Rd Bangkok, Thailand. Demographic data, clinical manifestations, causative organisms, Bangkoknoi, Bangkok 10700 histologic features, treatment, and outcome were investigated. Thailand Results The total cases in a 4-year period numbered 27. The male to female ratio was approximately 1 : 1. Mycetoma was most common, followed by chromoblastomycosis. Supported by Siriraj-China Medical Actinomycetoma was similar in incidence to eumycetoma. The only causative organism Board, Faculty Research Grant, that could be identified among the mycetoma cases was Cladosporium carrionii, which Faculty of Medicine, Siriraj Hospital, caused mycetoma of the buttock of an aplastic anemia patient at the site of bone marrow Mahidol University, Bangkok, Thailand aspiration. Surgical treatment was recommended for eumycetoma. Chromoblastomycosis was caused by C. carrionii and F. compactum and responded well with itraconazole orally. Mycotic abscesses were found in four cases, basidiobolomycosis in two cases, and cutaneous nocardiosis in one case. Cotrimoxazole was recommended in the treatment of actinomycetoma, cutaneous nocardiosis, and basidiobolomycosis. Conclusions Localized, chronic, slow, progressive, and usually asymptomatic were the main cutaneous manifestations of deep fungal and higher bacterial skin infections. A skin biopsy for histologic study and culture identification should be performed in every suspected case. The causative organisms were found in the histologic sections of every case, but only about one-third were found by culture. Introduction Deep fungal and higher bacterial skin infections occur primarily in tropical and subtropical regions. The etiologic agents are traumatically introduced into tissue, usually through occupational exposure. The skin lesions enlarge slowly and often asymptomatically so that it may be a long time, months to years, before treatment is sought. Mycetoma and chromoblastomycosis are the well-known entities of this group, but a variety of cutaneous mani- festations can also occur. The diagnosis is confirmed by histopathologic study and culture identification from skin lesions. Surgical and/or medical treatment is chosen accord- ing to the etiologic agent and clinical lesion. In this series, cases were collected with a provisional diagnosis of deep fungal infections primarily or by referral © 1999 Blackwell Science Ltd International Journal of Dermatology 1999, 38, 279–284 279 from other physicians. The demographic data, clinical manifestations, causative organisms, and treatment regi- mens were investigated. Materials and methods Twenty-seven patients, 13 men and 14 women, were examined in the Granuloma Clinic, Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand, during the years 1994–1997, with chronic, mostly asymptomatic, slow, progressive skin lesions suspicious of deep fungal and higher bacterial infections. Skin biopsy was taken from the lesions for histopathologic study and culture identification of the causative organisms. Special staining for fungal identification, Gomori–Methenamine Silver (GMS) and Periodic Acid–Schiff (PAS), and acid fast staining were

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Report

Deep fungal and higher bacterial skin infections in Thailand:clinical manifestations and treatment regimens

Punkae Mahaisavariya, MD, Angkana Chaiprasert, Dr.rer.nat., Apichati Sivayathorn, MD,and Supakan Khemngern, MABS

From the Departments of AbstractDermatology and Microbiology, Background Deep fungal and higher bacterial skin infections occur fairly frequently inFaculty of Medicine, Siriraj Hospital, Thailand.Mahidol University, Bangkok, Thailand

Methods Cases with a provisional diagnosis of deep fungal and higher bacterial

infections were prospectively collected from 1994 to 1997 in the Granuloma Clinic,CorrespondencePunkae Mahaisavariya, MD Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University,Siriraj Hospital, 2 Prannok Rd Bangkok, Thailand. Demographic data, clinical manifestations, causative organisms,Bangkoknoi, Bangkok 10700 histologic features, treatment, and outcome were investigated.Thailand

Results The total cases in a 4-year period numbered 27. The male to female ratio was

approximately 1 : 1. Mycetoma was most common, followed by chromoblastomycosis.Supported by Siriraj-China Medical

Actinomycetoma was similar in incidence to eumycetoma. The only causative organismBoard, Faculty Research Grant,

that could be identified among the mycetoma cases was Cladosporium carrionii, whichFaculty of Medicine, Siriraj Hospital,caused mycetoma of the buttock of an aplastic anemia patient at the site of bone marrowMahidol University, Bangkok, Thailand

aspiration. Surgical treatment was recommended for eumycetoma. Chromoblastomycosis

was caused by C. carrionii and F. compactum and responded well with itraconazole orally.

Mycotic abscesses were found in four cases, basidiobolomycosis in two cases, and

cutaneous nocardiosis in one case. Cotrimoxazole was recommended in the treatment of

actinomycetoma, cutaneous nocardiosis, and basidiobolomycosis.

Conclusions Localized, chronic, slow, progressive, and usually asymptomatic were the

main cutaneous manifestations of deep fungal and higher bacterial skin infections. A skin

biopsy for histologic study and culture identification should be performed in every

suspected case. The causative organisms were found in the histologic sections of every

case, but only about one-third were found by culture.

Introduction

Deep fungal and higher bacterial skin infections occur

primarily in tropical and subtropical regions. The etiologic

agents are traumatically introduced into tissue, usually

through occupational exposure. The skin lesions enlarge

slowly and often asymptomatically so that it may be a

long time, months to years, before treatment is sought.

Mycetoma and chromoblastomycosis are the well-known

entities of this group, but a variety of cutaneous mani-

festations can also occur. The diagnosis is confirmed by

histopathologic study and culture identification from skin

lesions. Surgical and/or medical treatment is chosen accord-

ing to the etiologic agent and clinical lesion.

In this series, cases were collected with a provisional

diagnosis of deep fungal infections primarily or by referral

© 1999 Blackwell Science Ltd International Journal of Dermatology 1999, 38, 279–284

279

from other physicians. The demographic data, clinical

manifestations, causative organisms, and treatment regi-

mens were investigated.

Materials and methods

Twenty-seven patients, 13 men and 14 women, were examined

in the Granuloma Clinic, Department of Dermatology, Faculty of

Medicine, Siriraj Hospital, Mahidol University, Bangkok,

Thailand, during the years 1994–1997, with chronic, mostly

asymptomatic, slow, progressive skin lesions suspicious of

deep fungal and higher bacterial infections. Skin biopsy was

taken from the lesions for histopathologic study and culture

identification of the causative organisms. Special staining for

fungal identification, Gomori–Methenamine Silver (GMS) and

Periodic Acid–Schiff (PAS), and acid fast staining were

280 Report Deep fungal and higher bacterial skin infections in Thailand Mahaisavariya et al.

performed in addition to hematoxylin and eosin staining. For

mycologic and higher bacterial culture, each biopsy specimen

was cut into very small pieces using a sterile technique and

then inoculated on four slants of Sabouraud dextrose agar

(SDA) and SDA plus chloramphenicol (50 µg/mL). All tubes

were incubated at room temperature and examined for visible

colonies every week until 6 weeks. The fungi or bacteria were

identified by macroscopic morphology, microscopic morphology,

staining properties, and some biochemical characteristics.

Demographic data, character of the skin lesion (site, size,

number, morphology), histologic findings, microbiologic

findings, and treatment modalities were recorded.

Results

Demographic dataFrom a total of 27 cases, 13 were men and 14 were women

(age 15–67 years; mean, 46.85 6 16.19 years). Thirteen

cases were field workers, eight housewives, two factory

employees, and one each a teacher, soldier, shop-keeper,

and clerk. Seventeen cases came from rural areas and ten

cases lived in big cities. Only two cases were immunocom-

promised from their underlying diseases: one had nephrotic

syndrome and was being treated with corticosteroid (Case

3, Table 1) and one had aplastic anemia (Case 7).

Clinical manifestations and causative organismsThe main causative organisms were found in two groups:

filamentous higher bacteria and true fungi. Filamentous

higher bacteria caused actinomycotic mycetoma and cuta-

neous nocardiosis. The cutaneous lesions caused by true

fungi were of four types: mycetoma, chromoblastomycosis,

mycotic abscesses, and basidiobolomycosis (Table 2).

Mycetoma, which is characterized by a firm, usually

painless, tumor-like mass with a sinus tract discharging

pus that contains granules or grains of the causal agent,

was found in 14 cases. Half of the mycetoma cases were

caused by filamentous higher bacteria and the other half

were caused by true fungi, dematiaceous fungi (four cases),

and hyaline molds (three cases). Only a single lesion was

found in each patient and the common site was the foot

(ten cases) (Table 1). The other four skin lesions were

found on the thigh (Cases 3 and 14), left chest wall without

history of previous trauma (Case 12), and at the site of

bone marrow aspiration on the left buttock of an aplastic

anemia patient (Case 7). The causative organism was

found as sulfur granules for actinomycotic mycetoma or

eumycotic grains, either black or hyaline fungi, for

mycetoma in the histologic section of every case, but culture

identification was performed in only 10 cases. Two cases

of actinomycotic mycetoma and two cases of eumycotic

mycetoma were not cultured (Table 2). Five actinomycotic

cases that were cultured revealed no growth. Five eumycotic

International Journal of Dermatology 1999, 38, 279–284 © 1999 Blackwell Science Ltd

cases showed no growth in two cases, and a fungal colony

in three specimens. Cladosporium carrionii was identified

from one specimen and the other two specimens were

nonsporulate septate hyaline fungi.

Chromoblastomycosis was found in six cases. The char-

acteristic verrucous hyperkeratotic plaque with a black

dot was found in three cases. Another three cases were

violaceous hyperkeratotic annular plaque (Case 16), hyper-

keratotic nodule (Case 19), and subcutaneous nodule (Case

20). C. carrionii was identified from three specimens,

F. compactum from one specimen, and the other two cases

were not cultured.

Mycotic abscesses, which are characterized by a soft,

cystic mass without or with a very slight sign of inflamma-

tion, were found in four cases: as a single lesion in three

cases and multiple lesions in one case. Disseminated mycotic

abscesses were caused by Penicillium marneffei (Case 24).

In three patients who had single lesions the causative

organisms were found in the abscess in histologic section

as hyaline septate hyphae in one case, which was identified

as Acremonium species (Case 23), and as brown septate

hyphae in the other two cases, which grew nonsporulate

septate black mold in one case (Case 22) and the other

case was not cultured (Case 21).

Basidiobolomycosis, which is the rare form of deep

fungal infection caused by nonseptate fungi, characterized

by a slow-growing, asymptomatic, plate-like lump, was

found in two cases (Cases 25 and 26). The causative

organism was identified as Basidiobolus ranarum in both

cases.

Cutaneous nocardiosis was found in one case (Case 27)

which manifested as a single hyperkeratotic nodule on the

dorsum of the hand. The causative organism was identified

as Nocardia asteroides.

Histologic findings

Suppurative granuloma was the main histopathologic find-

ing in all lesions. Pseudoepitheliomatous hyperplasia of the

epidermis was the associated feature in chromoblasto-

mycosis. Mycotic abscesses were found in the deep dermis

with granuloma formation surrounded by fibrous capsules

at the wall of the abscess. Dematiaceous fungi were easily

seen in hematoxylin and eosin stained sections. Hyaline

fungi were detected by special stains (GMS and PAS).

Actinomycotic grains, sulfur granules, which appeared as

round to oval bodies up to 300 µm in diameter, composed

of clumped colonies of bacteria with peripherally radiating

club-shaped filaments (Splendore–Hoeppli phenomenon),

were found within microabscesses in suppurative granul-

oma in hematoxylin and eosin stained and specially

stained sections.

Mahaisavariya et al. Deep fungal and higher bacterial skin infections in Thailand Report 281

Table 1 Character of the patients, treatment, and outcome

No. Sex Age Site Diagnosis Histology Culture Treatment Outcome/follow-up

(years) (months) (months)

1 F 33 Foot Eumycetoma Hyaline eumycotic grain Nonsporulate Itraconazole (48) Not improved

septate mold

2 F 27 Foot Eumycetoma Hyaline eumycotic grain NG† Itraconazole (36) Not improved (36)

3 F 35 Thigh Eumycetoma Hyaline eumycotic grain Nonsporulate Excision Cure (12)

septate mold

4 M 44 Foot Eumycetoma Black eumycotic grain ND* No treatment Loss to follow-up

5 F 42 Foot Eumycetoma Black eumycotic grain ND Excision Cure (12)

6 M 52 Buttock Eumycetoma Black eumycotic grain NG Itraconazole (24) Slightly improved (24)

7 M 52 Buttock Eumycetoma Suppurative granuloma C. carrionii Amphotericin B Cure (24)

8 F 22 Foot Actinomycetoma Sulfur granule NG Cotrimoxazole (8) Cure (12)

9 F 60 Foot Actinomycetoma Sulfur granule NG Cotrimoxazole (8) SCC on top scar (14)

10 M 41 Foot Actinomycetoma Sulfur granule ND Cotrimoxazole (3) Cure (18)

11 M 43 Foot Actinomycetoma Sulfur granule NG Cotrimoxazole (3) Loss to follow-up

12 F 61 Chest wall Actinomycetoma Sulfur granule ND Cotrimoxazole (9) Cure (12)

13 F 23 Foot Actinomycetoma Sulfur granule ND Cotrimoxazole (9) Cure (12)

14 M 63 Thigh Actinomycetoma Sulfur granule NG Cotrimoxazole (2) Improved (still follow-up)

15 M 49 Leg Chromoblastomycosis Medlar body F. compactum Itraconazole (18) Cure (18)

16 M 57 Forearm Chromoblastomycosis Pseudoepitheliomatous C. carrionii Itraconazole Cure (24)

hyperplasia with mixed cell

granuloma

17 M 67 Leg Chromoblastomycosis Medlar body C. carrionii Itraconazole (8) Cure (14)

18 M 65 Arm Chromoblastomycosis Pseudoepitheliomatous C. carrionii Itraconazole (2) Improved (2)

hyperplasia with mixed cell

granuloma

19 F 63 Wrist Chromoblastomycosis Medlar body ND Excision Cure (6)

20 F 62 Foot Chromoblastomycosis Suppurative granuloma with ND Excision Cure (12)

brown hyphae

21 F 42 Buttock Pheohyphomycosis Clump of black hyphae ND Excision Cure (24)

22 F 80 Foot Pheohyphomycosis Brown hyphae Nonsporulate Excision Cure (24)

septate mold

23 M 67 Shin Mycotic abscess Hyaline hyphae Acremonium Excision Cure (23)

24 F 57 Disseminate Penicilliosis Abscess with yeast-like organism P. marneffei Itraconazole (15) Not improved (24)

25 F 38 Arm Basidiobolomycosis Broad, nonseptate hyphae with B. ranarum Cotrimoxazole (3) Cure (24)

Splendore–Hoeppli phenomenon

26 F 15 Abdomen Basidiobolomycosis Broad, nonseptate hyphae with B. ranarum Cotrimoxazole (24) Much improved (24)

and thigh Splendore–Hoeppli phenomenon

27 M 62 Finger Nocardiosis Mixed cell granuloma N. asteroides Cotrimoxazole (2) Improved (2)

*ND, not done. †NG, no growth.

Treatment regimensActinomycotic mycetoma, cutaneous nocardiosis, and

basidiobolomycosis were treated with cotrimoxazole, two

tablets twice daily orally, with a favorable response. The

patients were treated until the skin lesions were completely

resolved. The duration of treatment ranged from 3 to 8

months. For eumycotic cases, mycetoma, mycotic abscesses,

and chromoblastomycosis, surgical excision was the curat-

ive treatment. In cases where surgical treatment could not

be performed easily or complete surgical excision could

not be carried out, antifungal drugs, i.e. itraconazole and

amphotericin B, were tried. Most cases were cured after a

single surgical procedure, except for one case with a deep

mycotic abscess on the buttock which was excised three

© 1999 Blackwell Science Ltd International Journal of Dermatology 1999, 38, 279–284

times. Itraconazole was tried at a dosage of 200 mg daily

with a favorable result for chromoblastomycosis, but not

for mycetoma and disseminated mycotic abscesses caused

by P. marneffei. The duration of treatment for chromoblas-

tomycosis caused by C. carrionii and F. compactum ranged

from 5 to 18 months. Amphotericin B was tried in one

case of mycetoma with aplastic anemia with a cumulative

dose of 1 g. The patient responded quite well and the

lesion healed completely after 3 months of treatment

without relapse during 2 years of follow-up.

Discussion

Thailand is an agricultural country in a subtropical region

with hot and humid weather all year round. Both the

282 Report Deep fungal and higher bacterial skin infections in Thailand Mahaisavariya et al.

Table 2 Summary of causative organisms, treatment, and outcome

Diagnosis ( n) Organisms ( n) Treatment ( n) Outcome ( n)

Mycetoma (14)Eumycetomic (7) C. carrionii (1) Itraconazole (3) Cure (3)Hyaline (3) Nonsporulate (2) Amphotericin B (1) Not cured (3)Dematiaceous (4) NG* (2), ND† (2) Excision (2)‡ Loss to follow-up (1)Actinomycotic (7) NG (5) Cotrimoxazole (7) Cure (5)

ND (2) Improved (2)Chromoblastomycosis (6) F. compactum (1) Itraconazole (4) Cure (6)

C. carrionii (3) Excision (2)ND (2)

Mycotic abscess (4) Acremonium (1) Excision (3) Cure (3)Single (3) P. marneffei (1) Itraconazole (1) Not cured (1)Multiple (1) Nonsporulate (1)

ND (1)Basidiobolomycosis (2) B. ranarum (2) Cotrimoxazole (2) Cure (1)

Much improved (1)Nocardiosis (1) N. asteroides (1) Cotrimoxazole (1) Cure (1)

*NG, no growth. †ND, not done. ‡One case was lost to follow-up. n, number of cases.

geography and the way of life are important factors in

acquiring deep fungal and higher bacterial skin infections.

Our patients came from all parts of the country, both

urban and rural areas. Middle-aged farmers predominated.

The sites of predilection were the extremities, especially

the hands and feet, as previously reported,1–4 which might

support traumatic inoculations as the route of entry of the

organism although most of them could not be recognized.

Uncommon locations, such as the head and neck,3,5,6 back,

and perineum,3 were not found in our series. Mycetoma

was most common, followed by chromoblastomycosis. The

causative organisms were found in al histologic sections,

but not in all cultures.

The mycetoma cases in our series were caused by actino-

mycetes and fungi, in equal number, which was different

from the report from Brazil4 stating that actinomycetoma

was about twice as common as the eumycotic form. The

most common organism of eumycetoma are Madurellagrisea,3,4 M. mycetomatis,3,4 Scedosporium apiospermum,4

Acremonium kiliense,3 A. falciforme,3,7 and Pyrenochaetaromeroi.3 Rare species that have been reported include

Arthrographis kalrae8 and Microsporum audouinii.6 In our

series, only three cases could be cultured. The only single

case was identified as C. carrionii and was successfully

treated with amphotericin B. The other two cases could

not be identified due to nonsporulation. Surgical treatment

was more effective than itraconazole for eumycetoma cases

in our series. A combination of medical and surgical

treatment was recommended in previous reports.1,9,10

Encouraging improvement was reported in the treatment

of eumycetoma due to M. grisea8 and A. falciforme7 with

itraconazole. Oral ketoconazole at a dosage of 400 mg

International Journal of Dermatology 1999, 38, 279–284 © 1999 Blackwell Science Ltd

daily for 8 to 24 months was tired in 10 eumycetoma cases

due to M. grisea, M. mycetomatis, P. romeroi, A. kiliense,

and A. falciforme with favorable results.3 Cotrimoxazole

was recommended for the treatment of actino-

mycetoma.1,5,9–12 In severe and recalcitrant cases, amikacin,

either alone or in combination with cotrimoxazole,13 and

amoxycillin plus clavulanic acid14 were recommended.

The causative organisms of chromoblastomycosis in our

series were C. carrionii and F. compactum which were the

common species in previous reports.15–19 The patients

responded well with itraconazole as well as surgical

treatment.

Mycotic abscess has seldom been reported in the litera-

ture. Both hyaline and dematiaceous fungi, as well as

higher bacteria (Nocardia species), could be the causative

organisms. The species that have been reported include

Exophiala jeanselmei,20 Phialaphora gougerotii,21

Pseudallescheria boydii,22 and Nocardia otitidiscaviarum.23

Our cases were caused by both hyaline and dematiaceous

fungi. Only hyaline fungi were identified as Acremoniumspecies and P. marneffei. Disseminated penicilliosis caused

by P. marneffei is one of the most common opportunistic

infections in AIDS patients in northern Thailand.24,25 The

cutaneous manifestations that have been reported include

multiple umbilicated papules,24,26 predominantly on the

face and upper extremities, palatal papules,24 and chronic

genital ulcer.24 Bamboo rat is the only known nonhuman

host of P. marneffei, but a history of exposure to or

consumption of bamboo rat was not a risk factor for

infection in AIDS patients.27 In addition, it occurs more

commonly in the rainy season.25 Chariyalertsak et al.25

suggested that an environmental reservoir of organisms in

Mahaisavariya et al. Deep fungal and higher bacterial skin infections in Thailand Report 283

the soil may be associated with P. marneffei infections.

Our patient who had disseminated penicilliosis manifested

differently from the previous report. She was an HIV-

negative patient and did not have any underlying disease

which would cause an immunodeficiency state. P. marneffeiwas cultured from the skin lesions, which were multiple,

large, cystic masses, and from the bone marrow aspiration.

She lived in the central part of Thailand and her neighbor

raised bamboo rat for sale. Amphotericin B,25,28 ketocona-

zole,25 and itraconazole25,29 were reported to yield success-

ful treatment of penicilliosis. Our patient responded to

initial itraconazole therapy, but she had many recurrences

during a 2-year follow-up period. She was lost to follow-

up until 1 year later when we were informed that she had

died from this illness.

Basidiobolomycosis is an uncommon deep mycosis in

the entomophthoromycosis group which has been

reported from Africa and Latin America. The reported

species include Basidiobolus haptosporus30–33 and

B. meristosporus, which is a saprophyte of amphibians

and reptiles.34 The causative organism in our cases was

B. ranarum which is now the correct name for the species

described in the previous reports. The clinical manifestation

was characterized by a hard, deep, non-tender, infiltrating,

slowly progressive plaque, which can simulate deep sclero-

derma,35 a tumoral disease,35 or elephantiasis.36 The correct

diagnosis can be made by histologic study and culture.

The diagnostic histologic features were broad, nonseptate

hyphae surrounded by eosinophilic material (Splendore–

Hoeppli phenomenon) in mixed cell granuloma with

numerous eosinophils. The sites reported include the

trunk,34,35 buttock,35 shoulder,34 and upper part of the

limbs.35,36 They have been successfully treated by potassium

iodide, either alone32,33 or in combination with ketocona-

zole,30 itraconazole,35 and cotrimoxazole.32,36 Our cases

responded well with cotrimoxazole without any side-

effects.

Nocardia species can cause a variety of cutaneous mani-

festations that include mycetoma,38,39 lymphocutaneous

syndrome (sporotrichoid),38,39 superficial skin infections

such as pyoderma,38–40 pustules,41 cellulitis,39 subcutane-

ous nodules,42 and abscess.23 The reported species include

Nocardia brasiliensis,39,41 N. asteroides,39,42 and

N. caviae43 (N. otitidiscaviarum).23 The patients were

successfully treated with sulfur drugs, such as sulfon-

amide,39 cotrimoxazole,39,41 and dapsone, either alone or

in combination with other drugs, such as amikacin41

or minocycline.40 Our case presented with a hyperkeratotic

nodule caused by N. asteroides and responded well to

cotrimoxazole.

Conclusions

Deep fungal and higher bacterial infections are localized,

chronic, and slowly progressive skin diseases which are

© 1999 Blackwell Science Ltd International Journal of Dermatology 1999, 38, 279–284

rarely fatal but disfigure the affected parts. The causative

organisms can be found by histologic study and culture.

Mycetoma was the most common form in this group, with

the feet most commonly affected. Mycotic abscess and

basidiobolomycosis were the uncommon types. The extra-

ordinary case in our series was an HIV-negative woman who

had multiple disseminated abscesses caused by P. marneffei.Surgical treatment was recommended for the therapy of

eumycetoma and single mycotic abscess. Itraconazole was

effective for chromoblastomycosis caused by F. compactumand C. carrionii. Cotrimoxazole was effective for actinomy-

cotic mycetoma, cutaneous nocardiosis, and basidiobolo-

mycosis.

Acknowledgment

Professor Visanu Thamlikithul, MD, Chief of Clinical

Epidemiology Unit, Office for Research and Development,

Faculty of Medicine, Siriraj Hospital, Mahidol University,

assisted in the project.

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