“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?

Help?!?Help?!?

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

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