Diagnosis of Deep Seated Cutaneous Mycoses (DSCM)

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Diagnosis of Deep Seated Cutaneous Mycoses (DSCM)
Practical Exemplification of Current State of
Art Cristiana Popp , Sabina Zurac , Razvan
Andrei , Tiberiu Tebeica, Florica Staniceanu,
Virginia Chitu, Cleo Rosculet, Adrian
Streinu-Cercel Colentina University
Hospital Matei Bal? National Institute of
Infectious Diseases
DSCM are rare lesions occurring in imunosupressed
patients, sometimes with critical evolution due
to multiple factors including immune status,
associated diseases and poor therapy response.
That emphasizes the importance of early and
accurate diagnosis despite the confounding
clinical and histopathological aspects. Keys of
diagnosis are the high level of susceptibility
and patients multidisciplinary approach.
No Age/Sex Localization Cause of immuno-supression Pathological findings Fungi appearance Fungi type Evolution
1 42/F Forearm Corticotherapy for LE Giant-cell inflammation with polymorphous inflammatory cells and suppurative and necrotic areas Spores of 5-15µ spherules with endosporulation Coccidioidossis Good
2 62/F Periocular Diabetes mellitus Suppurative necrosis important polymorphous inflammatory infiltrate impressive vascular invasion Broad, thin-walled, hyaline, aseptate hyphae irregular branching Mucormycosis Sepsis, death
3 33/M Forearm None, after DSCM diagnosis, he tested positive for HIV Dermal inflammatory infiltrate with numerous histiocytes with foamy cytoplasms Small, mildly pleomorphic yeasts with narrow-based buds, melanin no hyphae Criptoccocosis Difficult
4 64/F Pretibial Corticotherapy for RP Granulomatous inflammatory infiltrate with suppurative foci Short, septated, dichotomously branched hyphae, rare yeasts Aspergillosis (second biopsy) Very good
5 56/M Arm Postirradiation Ischemic dermal necrosis Numerous septated hiphae and rare yeasts Aspergillus Candida Difficult
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Case 1
HE
PAS
Case 2
HE
Grochott
The fungal elements are rather inconspicuous in
HE stain. Very important for diagnosis is the
routine examination of at least one fungal stain
for each inflammatory cutaneous lesion in
immunosupressed patients (PAS, Grochott)
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HE
HE
HE
HE
PAS
Grochott
Grochott
Grochott
Grochott
PAS
Case 4
Case 5
Case 3
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• Protocols of British Society for Medical Mycology
• The pathologist is not called to establish the
  exact type of fungi, the pathological report must
  include
• the presence and absence of yeast forms,
• the presence and absence of hyphae,
• whether hyphae are septate or aseptate,
• presence of melanin,
• the size of fungi,
• cellular location
• any specialised structures

The appearance of fungi can be sufficient to
guide treatment, but the golden standard requires
either immunohistochemical confirmation of the
specific type or confirmatory cultures.
Patients with poor immune status have, usually, a
long, difficult evolution, with possible fatal
outcome due to systemic dissemination of fungal
infection.
HE
Bronchopneumonia (case 2)
Applying these standards in routine examination
of inflammatory skin biopsies micotic infection
can be identified as cause of inflammation, thus
improving management of immunocompromised
patients.