P281 Healthy adult with arm swelling and new onset burning pain

POSTER SESSION 2, SEPTEMBER 22, 2022, 12:30 PM - 1:30 PM: INTRODUCTION: Cladosporium cladosporioides is a dematiaceous fungal agent that is known to produce a variety of clinical manifestations such as cutaneous and subcutaneous infection, corneal infection, pulmonary fungal infection, and rarely central nervous system infection. Several cases of subcutaneous mycosis have been reported from Assam, India. We are describing a similar case from Gujarat, India. CASE HISTORY: A 36-year-old healthy, and muscular male farmer residing in central Gujarat presented with painless nodular swelling with normal overlying skin over the posterior aspect of the left arm for the last 3-4 years. He noticed a gradual increase in the size of this swelling and numbness for the last 4 months and burning sensations for the last 10 days before presentation to the surgeon. Local part ultrasound showed a subcutaneous soft tissue lesion. Excision biopsy reported invasive fungal infection and patient was referred for further evaluation to an infectious disease facility (Fig. 1a). He had no other symptoms and comorbidities. Patient didn't recall any trauma in the past. Direct microscopic examination with calcofluor white stain from surgical site scrapping revealed mycelial structure (Fig. 1b) and yielded pure growth of a dematiaceous fungus on Sabouraud dextrose agar medium, brown to blackish colony (Fig. 1c) with olive color on the backside (Fig. 1d) after 6 days. Lactophenol cotton blue stain preparation of culture isolate showed mycelial elements with morphology suggestive of C. cladosporioides (Fig. 1e), which was confirmed at the National Culture Collection for Pathogenic Fungi, PGI Chandigarh. Review of histopathology revealed a nodule with dense acute on chronic inflammation composed of lymphocytes, plasma cells with many neutrophils with abscess containing brightly eosinophilic structures with many PAS positive septate, thin and thick walled, branching, irregularly shaped, bullous hyphae surrounded by neutrophilic boarder (Splendor Hoeppli phenomenon) (Fig. 1f). Patient was treated with capsule itraconazole 200 mg three times a day for three days followed by 200 mg twice a day along with terbinafine and total surgical excision of the subcutaneous nodule. Patient achieved a therapeutic itraconazole level (1.4 mg/l) after 1 week. Patient is currently receiving treatment. DISCUSSION: Subcutaneous mycosis is endemic in Assam. Several cases of subcutaneous chromoblastomycosis caused by C. cladosporidiosis mainly involving the lower limbs were reported from Assam. It mostly affects males engaged actively in outdoor activities during their productive age ranged from 20 to 50 years. It affects a relatively healthy, immunocompetent host and have a long history (in years) of asymptomatic nodule/swelling before diagnosis. Treatment comprises of prolonged antifungal treatment with itraconazole along with surgical excision.