A 67-year-old man presented at our clinic with a two-month history of multiple cutaneous ulcers on his right foot. Physical examination revealed multiple areas of necrotic ulceration with eschar formation and purulent discharge on dorsal surface and the 4th toeweb of right foot (Fig. 1). At first, we did not examine the peripheral pulses because the patient denied claudication or right leg pain. We initially suspected vascular ulcer, but although we recommended visiting the vascular surgery clinic, the patient refused the consultation.
Fig. 1. (A), (B) Necrotic ulcerations with eschar on the right
Histopathologic examination disclosed severe necrosis and ulceration of the epidermis extending to the dermis. It also revealed septate fungal hyphae and spores in the ulcer base (Fig. 2). We perforated a fungus culture; seven consecutive fungal cultures grew pure and similar colonies on Sabouraud dextrose agar. This fine cottony aeromycelium with banana shaped multiseptate macroconidia and a pinkish red color on the back of the agar plate was consistent with the characteristic findings of a Fusarium solani colony (Fig. 3). There was no growth for bacteria including mycobacteria. Baseline investigations revealed elevated C-reactive protein (1.9 mg/d).
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Fig. 2. Elongated and septate fungal hyphae and spores were found in the lesion (D-PAS, x 200)
A diagnosis of Fusarium solani infection occurring in immunocompetent patient was made. The patient treated itraconazole 200 mg once daily for 3 weeks, but the ulcers showed only slight improvement. The patient then failed to follow-up his treatment.
Fig. 3. (A) Fungus culture showing whitish cottony rapid-growing colonies on the 6th day and pinkish red color on the base (25 °C, Sabouraud dextrose agar). (B) Banana shaped multiseptate macroconidia (lactop – henol cotton blue stain, x 400)
After one month, the patient revisited with aggravated ulcers and a cyanotic and edematous right foot. Physical examination revealed reduced palpable pulse on right dorsalis pedis and right popliteal arteries. These findings suggested ASO, so an arteriography was performed, which showed very poor circulation with severe obstruction of the common iliac and superficial femoral arteries (Fig. 4). A femoro-popliteal bypass with thrombolytic therapy corrected this vascular insufficiency. At that time, he had toxic hepatitis due to herbal medication, so we could not prescribe any antifungal medication. But after the surgery, ulcerative lesions improved rapidly with a simple wet dressing and topical antifungal agent.
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Fig. 4. The arteriogram demonstrates an occlusive right common iliac artery and superficial femoral