A 76-year-old male presented to our institution with chronic cough and intermittent haemoptysis for 2 months. He had completed standard anti-TB therapy 10 years prior for smear positive cavitatory pulmonary Mycobacterium tuberculosis. Other past medical history was significant for rheumatic fever. He was a lifelong non-smoker. Thoracic computed tomography (CT) done 7 years previously demonstrated traction bronchiectasis and chronic scarring within the right upper lobe. He remained symptomatically well until this presentation.\nHis physical examination revealed bronchial breath sounds in the right upper lobe. Thoracic CT demonstrated fibrocystic change in an incompletely collapsed right upper lobe. There was now a large cavity with a new 2.1-cm round mass (Fig. A, C).\nWe proceeded to perform flexible bronchoscopy (Olympus 3.2 mm) under conscious sedation. After traversing two segments of the bronchi, an abnormal rounded mass was seen obstructing the anterior segment of the right upper lobe (Fig. A). Microbiological culture of bronchoalveolar lavage (BAL) from the right upper lobe cavity subsequently isolated both Staphylococcus aureus and Aspergillus fumigatus. He was commenced on a one week course of flucloxacillin as well as a prolonged course of the anti-fungal drug posaconazole. He was subsequently discharged and electively readmitted a few weeks later to facilitate bronchoscopic removal of the mycetoma.\nAt repeat flexible bronchoscopy, a flexible cryoprobe was inserted via the bronchoscope into the cavity. However, en bloc removal of the mass was not possible. The cryoprobe was removed and hot forceps was introduced to subdivide the mass into various smaller parts. Then the cryoprobe was reintroduced and the subdivided mass was removed piecemeal. Washing of the cavity was then performed with normal saline until all macroscopically visible mycetoma had been removed. Inspection of the empty cavity revealed inflamed haemorrhagic mucosa (Fig. B).\nThe obtained mass was sent for histopathological analysis. Microscopically, it demonstrated inflamed bronchial mucosa, abundant fungal organisms as well as a bacterial colony consistent with Gram-positive cocci. There was no evidence of invasive fungal infection. The case was discussed at our institution's multidisciplinary respiratory meeting, where a diagnosis of mycetoma was inferred. He was continued on oral posaconazole. Radiological and bronchoscopic surveillance at 3 months demonstrated no reoccurrence of the mycetoma (Figs. B, B, D).
A 25-year-old female with a two-year history of erythema, papules, nodules, and scales on her sole of left foot was presented to our outpatient center. She has no history of autoimmue disease and untreated with immunosuppressive therapy. Considering her pregnancy, she was not given treatments for 1 year. The left foot skin lesion on the medial and lateral margins and on the fourth toe dorsum became enlarged with evident pain after more than 1 year (Fig. ). Approximately 1 month before visiting our department, she received treatment ineffectively in a local clinic, and the diagnosis was unclear.\nSamples were obtained by the scraping of lesion and for light microscopy. Hyphae were observed by microscopic examination (Fig. ).\nWe carried out a skin tissue biopsy, which showed multiple granulomatous nodules (Fig. ). The Ziehl–Neelsen stain was negative. Periodic acid–Schiff (PAS) and Grocott methenamine silver (GMS) staining were carried out two times. Results were also negative. Biopsy specimens were also inoculated onto two kinds of media: Sabouraud’s dextrose agar (SDA), where one of which contained chloramphenicol and cycloheximide, and the other one contained chloramphenicol only. After being cultured on SDA at 27 °C for 7 days, spreading-woolly-white colonies grew on the inoculation sites of media containing chloramphenicol only and there,s no other colonies grew (Fig. ). The colonies produced an unpleasant smell like biogas. No colony was observed on the media with chloramphenicol and cycloheximide. Clamp connections, spicules, tear-like secretions, and medusa-like isomers were observed on the slide culture at 27 °C after 3 days (Fig. ). Urease activity tests were also performed. Trichophyton rubrum standard strain and the isolated strain were cultured on urease media at 27 °C for 7 days. The T. rubrum standard strain was negative, whereas the isolated strain turned red (Fig. ).\nSequencing of large subunit rDNA was performed by using the E.Z.N.A.™ Fungal DNA Mini Kit (Omega Biotek, USA). We utilized set primers for the region of internal transcribed spacer (ITS) and performed PCR. The PCR primers were ITS1: 5′-TCCGTAGGTGAACCTGCGG-3′ and ITS4: 5′-TCCTCCGCTTATTGATATGC-3′. The PCR-amplified DNA was matched with that of S. commune (Nos. KP 326677.1 and KP 004975.1) with a homology of 100%. After identification, the sequence was submitted to the GenBank (MF 495704).\nPathological finding and mycological examination indicated a cutaneous granuloma caused by S. commune. Oral itraconazole (100 mg) was applied twice a day. The rashes on the left foot and the pain regressed after 1 month of treatment (Fig. ). Follow-up is currently under way.