An unusual case of hyalohyphomycosis due to Purpureocillium lilacinum in a patient with myasthenia gravis

BACKGROUND AND PURPOSE: Purpureocillium lilacinum (previously known as Paecilomyces lilacinus) and Paecilomyces variotii cause hyalohyphomycosis. CASE REPORT: In this study, we present a case of multiple subcutaneous abscesses of the lower limbs due to Purpureocillium lilacinum in a patient with myasthenia gravis and uncontrolled diabetes. Subcutaneous involvement of the lower limbs with this fungus is an unusual presentation. Pus aspirate collected on multiple occasions revealed hyaline septate hyphae under microscopic examination and Purpureocillium lilacinum grew on Sabouraud Dextrose Agar. The patient was initially treated by surgical excision and itraconazole therapy. Swelling regressed but discharge was noticed from the excision site after three months of itraconazole therapy. Culture from the discharge material yielded the same fungal growth. Treatment was changed to ketoconazole and he responded. CONCLUSION: This case report emphasizes the importance of identifying Purpureocillium lilacinum at an unusual site like the lower limbs in an immunocompromised patient. Ketoconazole may be used as an alternative treatment option for hyalohyphomycosis caused by Purpureocillium lilacinum.