Case summary

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A 22 year old male presented with swelling and ulceration over the left great toe since six months. Patient, being an agriculturist by occupation, used to work in wet and damp soil. Initially he presented with swelling over the great toe followed by ulcer with discharging sinus containing black granules. There was no history of trauma. Patient was treated in local hospital, but with poor response to the treatment. The X-ray of left foot showed distortion and erosion of distal phalanx of great toe (Figure-1). Hematological and biochemical investigations were within normal limits. Patient was planned for amputation of great toe because of complete destruction of distal phalanx. Histopathology was reported as phaeohyphomycosis involving the bone.

Phaeohyphomycosis term was first introduced in 1974, meaning ‘‘condition of fungi withdark hyphae’’. It describes the brown to black color within the cell wall of the vegetativecells. Phaeohyphomycosis involves cutaneous, subcutaneous sites; paranasal sinus. Miscellaneous manifestations have included endocarditis, keratomycosis, endophthalmitis, peritonitis, various pulmonary presentations, osteomyelitis, rarely disseminated systemic infection (1). Infection occurs by molds found in soil, air, plants, organic debris. The most common route of exposure to humans is by means of inhalation or percutaneous inoculation (2). Phaeohyphomycosis is more of a histopathological diagnosis rather than a clinical entity. The different modalities of treatment of fungal osteomyelitis include chemotherapy with ketoconazole oritraconazole. Ketoconazole is the drug of choice. In case of failure of the antifungal therapy, radical treatment by surgical debridement or amputation may be required. In cases of chronic osteomyelitis with draining sinuses occurring in uncommon anatomic locations, fungal etiology should be suspected (3).

References

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1. Silveira F, Nucci M (2001) Emergence of black moulds in fungal disease:Epidemiology and Therapy. Curr Opin Infect Dis14: 679-684.
2. Khan SA, Hasan AS, Capoor MR, Varshney MK, Trikha V (2007) Calcanealosteomyelitis caused by exophiala jeanselmei in an immunocompetent child. A casereport . J Bone Joint Surg Am 89(4):859-62.
3. Welsh O (1991). Mycetoma: Current concepts in treatment. Int J Dermatol 30: 387-98.

Source(s) of Funding

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Competing Interests

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none

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