Phaeohyphomycosis caused by Exophiala jeanselmei treated with itraconazole

Phaeohyphomycotic cysts developed on the right knee of a 72-year-old woman undergoing immunosuppressive treatment for ulcerative colitis 6 years after accidental inoculation of soil in a bicycle accident. The lesions were red, firm, slightly raised, 0.5-1 cm in size and completely asymptomatic. The diagnosis was made by histopathological examination of three excised cysts and by repeated isolation of Exophiala jeanselmei in pure culture. The excised cyst walls contained large numbers of dematiaceous fungal elements in the form of hyphae, yeast-like cells and some cells dividing internally by a transverse septum. The patient was treated with 200 mg of itraconazole daily, but the treatment had to be stopped because of severe side-effects after 6 weeks. Histologically the cysts were cleared of dematiaceous elements, but E. jeanselmei could still be isolated from one of two skin biopsies 1 month after the end of therapy.