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

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 Balș” 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 patient’s multidisciplinary approach.

Case 1

Case 2

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)

HE

HE

PAS

Grochott

Case 3 Case 4

Grochott

HE

Grochott

Case 5

HE

PAS

Grochott

HE

Grochott

PAS

HE

Protocols of British Society for Medical MycologyThe 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

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.

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.

Bronchopneumonia (case 2)

HE