First reported case of Aspergillus nidulans eumycetoma in a sporotrichoid distribution

Mycetomas are chronic subcutaneous infections caused by either fungi (eumycetomas) or bacteria (actinomycetomas). Eumycetoma is commonly seen in tropical and subtropical climates, usually in males working in occupations prone to trauma. Aspergillus spp. are an uncommon cause of mycetomas.

We describe a patient with eumycetoma attributable to Aspergillus nidulans presenting in a sporotrichoid distribution.

A 45-year-old man with type 2 diabetes mellitus and hypertension presented with multiple lumps over the right lower limb of four months in duration. He had initially developed a solitary lesion over the right ankle, followed by multiple similar lumps which had spread upwards to involve the right thigh. The entire lower limb was edematous. The patient denied any trauma preceding the symptoms. Biopsy revealed pseudoepitheliomatous hyperplasia with extensive granulomatous infiltrate in the dermis and subcutaneous tissue. Grocott-Gomorri staining revealed fungal elements. Culture on Sabouraud's agar revealed a whitish colony that later turned green. Aspergillus nidulans mycetoma in a sporotrichoid distribution was diagnosed. The patient was started on oral itraconazole 200 mg twice daily, which resulted in complete regression of the lesions.

Aspergillus spp. have emerged as important opportunistic pathogens, especially in immunosuppressed patients. Aspergillus nidulans occurs frequently in soil, decaying vegetation, and water but has very rarely been described as a cause of mycetoma. The infection responds well to treatment with itraconazole, voriconazole, and amphotericin B. The current patient represents the first demonstration of A. nidulans mycetoma presenting in a sporotrichoid distribution.