Subcutaneous phycomycosis mimicking synovial sarcoma.

A 6-year-old girl presented to the pediatric surgery department with swelling of the right hand of 4 months’ duration. According to the patient’s parents, it started as a small nodule over the dorsum of the right hand which gradually increased in size covering nearly the whole of the hand. There was no history of preceding trauma or insect bite. She had no constitutional symptoms; however, she had limitation of movement of the fingers of the affected hand. The surgeon made a clinical diagnosis of synovial sarcoma. A biopsy specimen from the border of the lesion was obtained for histologic examination. Microscopic examination of the histologic section was not suggestive of this condition. Hence, she was referred to a dermatologist for expert opinion. On cutaneous examination, the right hand showed a single, large, well-defined, indurated mass involving the dorsal and ventral aspects, encircling the proximal portions of the fingers and thumb (Figs 1, 2). The skin over the swelling was nodular, shiny, and intact. On palpation, the mass was nontender, lying between the skin and the superficial fascia, and the examining fingers could be inserted under the smooth, well-defined upper edge. The patient’s general condition was good and regional lymph nodes were not enlarged. Laboratory data, including blood counts, erythrocyte sedimentation rate, stool examination for eggs and parasites, and fasting blood sugar, were all normal. X-Ray of the right hand showed soft tissue swelling without bone destruction or calcification. A repeat deep biopsy from the edge of the mass showed a dense granulomatous infiltrate in the dermis, consisting of plasma cells, histiocytes, neutrophils, and multinucleated giant cells, with a marked preponderance of eosinophils. A few large nonseptate hyphae were seen (Fig. 3), surrounded by bright granular eosinophilic material in the dermis. Culture for acid-fast bacilli and fungus was negative. The patient was treated with a saturated solution of potassium iodide. Initially, she was put on five drops of potassium iodide daily. Every week, the dose was increased by five drops until the patient started to complain of side-effects. The dose was then reduced by five drops and maintained. The maintenance dose was 30 drops, three times daily. There was complete regression of the mass after 3 months of therapy (Fig. 4). Maintenance therapy was continued for another 6 months. No recurrence of the lesion was noted during 11 months of follow-up. [ABSTRACT FROM AUTHOR]