Global Dermatology Grand Rounds:
Case of the Month: June 1996
submitted by Dr. Atalo Alanis

September 1996



August 1996

June 1996

May 1996

April 1996

July 1995

June 1995

May 1995

February 1995

 January 1995

Click on the thumbnail sketches to view the clinical (1&2), uroradiographic (3), skin H&E (4), vesicle wall H&E (5) and fungal culture images.

Chief Complaint: Recurrent Draining Sinuses and Hematuria

History of Present Illness: This is a 57 year old farmer with a 16 year history of a dermatologic condition diagnosed as a mycetoma of the right popliteal fossa. He has been treated with trimethoprim-sulfamethoxazole for two years with an apparent cure. The patient does not recall the doses he received. The condition recurred 6 months prior to presentation with fístulas in the right groin. He also had a urinary frequency with gross hematuria. He suffered from general poor health.

Laboratory Examinations:

Significant for a normocytic normochromic anemia. A vesicular biopsy was obtained to produce the H&E slide above.

Clinical Impression:

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Answers posted to the June 96 case:

Date: 02 Jul 1996 08:45:40 -0400
From: "
Subject: June 1996 Diagnosis

My diagnosis is chromoblastomycosis. I guess the patient may have been initially treated
with TMS for ulcerative lobomycosis. That an organism was cultured (with fluffy olive-gray)
colonies) and that the H&E; demonstrates septated "copper pennies" goes for chromomycosis.
F. pedrosi and P. verrucosa have been reported to spread to the CNS, but all types are
probably capable of hematogenous or lymphatic spread. I think that the vesicular biopsy
demonstrates the Splendore-Hoeppli phenomenon of Ab-Ag eosinophilic condensation.
Well, that's my guess.


Ahmet Tangoren, M.D., Ph.D. Dermatology Resident, UPenn, 1995-8

Date: Thu, 04 Jul 1996 01:09:03 -0600
From: Atalo Alanis

Dr. Ahmet Tangoren and all who participated:

The case of June is a man with an Actinomycetoma caused by Nocardia brasiliensis, insufficiently
treated with trimethoprim and sulphamethoxazole (picture Nº 1).

Several years after it had a dissemination to the bladder and the right groin by lymphatic via
(see the clinical picture Nº 2 and the intravenous urography Nº 3).

The direct examination (picture Nº 4) and the H/E slide (picture Nº 5), show a typical grane of
Nocardia brasiliensis.

The image of the Sabouraud´s culture is typical too: "popcorn like" (picture Nº 6).

This is a very common problem in the south of my country (Mexico) and several countries with
tropical weather.

Thank you for your participation.

Date: Mon, 08 Jul 1996 08:45:40 -0400
From: "Rhett Drugge, M.D."
Subject: Re: June 1996 Diagnosis

Dear Dr. Tangoren,

You wrote,
>I think the
>vesicular biopsy demonstrates Splendore-Hoeplii phenomenon of Ab-Ag
>eosinophillic condensation.
>Well, that's my guess. What's the answer?

I think that your response to the June 1996 case brings up
an interesting point which wasn't discussed in Dr. Alanis's
response about this case of Nocardia Brasiliensis.
The Splendore-Hoeppli phenomenon is relatively non-specific.
It describes granulomas with a necrotizing eosinophilic center,
surrounded by a ring of epithelioid cells, giant cells and
eosinophils. A quick review of the peer reviewed literature shows
that it has been seen secondary to silk sutures, phycomycoses,
actinomycoses, pityrosporum folliculitis, eosinophilic
gastroenteritis in the ferret, bronchcentric granulomatosis,
pulmonary blastomycosis, aspergillosis. The origin of this
rather non-specific phenomenon is controversial, thought by
some to be immune complexes derived from host serum proteins,
others have speculated that they are derived from host leukocytes
that aggregate in response to the commonly fungi, parasites or
inert foreign bodies.

Is this yet another example of the Splendore-Hoeppli phenomenon,
albeit the first reported in the setting of Nocardia Brasiliensis?
What is your opinion? ref.