“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.
What’s 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
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