“Subcutaneous nodules, an unexpected diagnosis, 20 .“Subcutaneous nodules, an unexpected diagnosis,

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  • Subcutaneous nodules, an unexpected diagnosis, 20 years

    ago after a fall in Namibia.

    Dr. Louis IdeJan Palfijn Ziekenhuis Gent

  • Communication with the pathologist

    30-year-old black male. Subcutaneous nodules right trunk, no

    ulceration, painless. Namibia Lommel. Namibia Lommel. All fixed, no culture. Something tropical?

  • Communication with the surgeon

    Umicore, laborour, zinc factory. Blood analysis totally normal (eosinophils,

    CRP, serology,). Chronic problem (20 years). Chronic problem (20 years). Large surgical excision removed all noduli.

  • Communication with the patient

    At the age of 10 years : problems started.

    He lives in Nothern He lives in Nothern Namibia the town of Ongwediva, situated in Ovambo.

  • Communication with the patient

    A town with farms, in summer the soil is dusty, desert-like, and thorn trees are scattered everywhere.

    Already excision two times, no medical Already excision two times, no medical treatment.

  • Whats your diagnosis?

    Help?!?Help?!?

  • Whats your diagnosis?

    A. Chromoblastomycosis B. Lobomycosis C. Mycetoma D. Sporothrichose D. Sporothrichose E. Other: scrofulosis, foreign body,

  • Diagnosis: mycology bacteriology?kleur afmetingen consistentie histologie verwekkers

    zwart 1 5 mm hard specifiek Madurella mycetomatis

    zwart 0,5 - < 2 mm

    hard fungisch Leptospheria senegalensis + andere

    zwart 0,3 0,6 mm

    hard fungisch Pyrenochaeta sp., Madurella grisea

    zwart 0,2 0,5 zacht fungisch Exophiala jeanselmeizwart 0,2 0,5 mm

    zacht fungisch Exophiala jeanselmei

    wit 0,5 1 mm zacht fungisch Pseudallescheria boydii

    wit/geel 0,5 1 mm hard fungisch Acremonium sp., Aspergillus nidulans, Neotestudinia rosatii

    wit/geel < 0,3 mm zacht genusniveau Nocardia brasiliensis, N. asteroides, N. caviae

    wit/geel 0,5 2 mm hard specifiek Streptomyces somaliensis

    wit/geel 1 3 mm zacht specifiek Actinomadura madurae

    rood 0,3 0,5 mm

    stevig specifiek Actinomadura pelletieri

  • Rippon Medical Mycology, 3th edition.

  • Confirmation?

    PCR negative Serology, relevant? Culture, negative (no reanimation). Ignace Surmont, Rod Hay. Ignace Surmont, Rod Hay. P. Destombes: specific histology.

  • Lode Op De Beeck (pathology) Joep Knol (surgery) Ignace Surmont (mycology) Wendy van de Sande (molecular biology) Alex Van Belkum (molecular biology) Emmanuel De Laere (molecular biology) Veerle Vanacker (climatology) Marjan Van Esbroeck (medical literature) Roderick Hay (final diagnosis) Manuela Popan, Schering-Plough (posaconazole) Manuela Popan, Schering-Plough (posaconazole)

    Conflict of interest : The author participated in a scientific advisory board after starting the treatment of this patient with posaconazole for which he received a fee

  • CCC

    Communication Connaissance Collaboration