Subcutaneous phycomycosis mimicking synovial sarcoma

A 6-year-old girl presented to the pediatric surgery department with swelli ng of the right hand of 4 months' duration. According to the patient's pare nts, it started as a small nodule over the dorsum of the right hand which g radually increased in size covering nearly the whole of the hand. There was no history of preceding trauma or insect bite. She had no constitutional s ymptoms; however, she had limitation of movement of the fingers of the affe cted hand. The surgeon made a clinical diagnosis of synovial sarcoma. A bio psy specimen from the border of the lesion was obtained for histologic exam ination. Microscopic examination of the histologic section was not suggesti ve of this condition. Hence, she was referred to a dermatologist for expert opinion. On cutaneous examination, the right hand showed a single, large, well-defin ed, 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 nontend er, lying between the skin and the superficial fascia, and the examining fi ngers could be inserted under the smooth, well-defined upper edge. The pati ent's general condition was good and regional lymph nodes were not enlarged . Laboratory data, including blood counts, erythrocyte sedimentation rate, st ool examination for eggs and parasites, and fasting blood sugar. were all n ormal. X-Ray of the right hand showed soft tissue swelling without bone des truction or calcification. A repeat deep biopsy from the edge of the mass s howed a dense granulomatous infiltrate in the dermis, consisting of plasma cells, histiocytes, neutrophils, and multinucleated giant cells, with a mar ked preponderance of eosinophils. A few targe nonseptate hyphae were seen ( Fig. 3), surrounded by bright granular eosinophilic material in the dermis. Culture far acid-fast bacilli and fungus was negative. The patient was treated with a saturated solution of potassium iodide. Init ially, 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 m aintenance dose was 30 drops, three times daily. There was complete regress ion 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 duri ng 11 months of follow-up.