Magnetic Resonance Imaging and Histopathological Aspects of Botryomycosis

Diogo Goulart Corrêa Leonardo Hoehl Carneiro Flavia Martins Costa About the authors

A 20-year-old woman presented with a growing mass on the plantar surface of the left foot that had been present for one year. She reported laceration trauma in this region six years earlier. The wound healed initially with topical antibiotics, but eventually, a palpable mass appeared. The patient was afebrile, had no skin discharge, and her hemogram was normal. Magnetic resonance imaging (MRI) demonstrated multiple clustered oval lesions affecting the soft tissues of the left foot, with heterogeneous gadolinium enhancement (Figure 1). After surgical resection, histopathological analysis revealed suppurative necrosis with fibrosis and an eosinophilic coating surrounding several gram-positive bacterial granules (Figure 2). S. aureus grew in the tissue culture. Cutaneous botryomycosis was diagnosed, and oral clindamycin was initiated.

FIGURE 1:
MRI of the left foot showing a large mass comprising multiple tiny clustered oval lesions affecting the left foot plantar soft tissues and infiltrating the flexor digitorum brevis and flexor hallucis brevis muscles and plantar fascia. The mass had a predominantly isointense signal on T1-weighted image with fat saturation (arrows in A) and hypointense signal on the T2-weighted image (arrows in B) due to the associated surrounding fibrous reaction; it showed heterogeneous gadolinium-enhancement (arrows in C). The lesion also presented restricted diffusion due to hypercellularity (arrows in D), and increased perfusion in its solid portions (arrows in E).

FIGURE 2:
Histopathological analysis revealed extensive suppurative necrosis with fibrosis, associated with an eosinophilic coating (thick arrows in A), surrounding bacterial granules (thin arrows in A), characteristic of the Splendore-Hoeppli phenomenon (original magnification, × 200). The bacterial granules were Gram-positive (arrows in B; original magnification, × 400).

Botryomycosis is a chronic suppurative bacterial infection that generally affects the skin and subcutaneous tissues. It has an insidious course, usually involving the extremities, and is associated with previous inoculating trauma, alcoholism, diabetes mellitus, and/or immunosuppression11. Eyer-Silva WA, Silva GARD, Ferry FRA, Pinto JFDC. Facial botryomycosis-like pyoderma in an HIV-infected patient: remission after initiation of darunavir and raltegravir. Rev Soc Bras Med Trop. 2017;50(2):277-9. Available from: https://doi.org/10.1590/0037-8682-0061-2016.
https://doi.org/10.1590/0037-8682-0061-2...
,22. John K, Gunasekaran K, Kodiatte TA, Iyyadurai R. Cutaneous botryomycosis of the foot: A case report and review of literature. Indian J Med Microbiol. 2018;36(3):447-9. Available from: https://doi.org/10.4103/ijmm.IJMM_18_347.
https://doi.org/10.4103/ijmm.IJMM_18_347...
. It can cause extensive destruction and disfigurement, associated with non-healing ulcers, sinuses, and fistulae. S. aureus is most commonly implicated. Botryomycosis is a misnomer still used for historical reasons11. Eyer-Silva WA, Silva GARD, Ferry FRA, Pinto JFDC. Facial botryomycosis-like pyoderma in an HIV-infected patient: remission after initiation of darunavir and raltegravir. Rev Soc Bras Med Trop. 2017;50(2):277-9. Available from: https://doi.org/10.1590/0037-8682-0061-2016.
https://doi.org/10.1590/0037-8682-0061-2...
.

The MRI appearance of botryomycosis has rarely been described22. John K, Gunasekaran K, Kodiatte TA, Iyyadurai R. Cutaneous botryomycosis of the foot: A case report and review of literature. Indian J Med Microbiol. 2018;36(3):447-9. Available from: https://doi.org/10.4103/ijmm.IJMM_18_347.
https://doi.org/10.4103/ijmm.IJMM_18_347...
; however, the presence of multiple rounded or oval clustered lesions in a limb with previous trauma should lead to suspicion of botryomycosis. Differential diagnoses include mycetoma and skin tumors22. John K, Gunasekaran K, Kodiatte TA, Iyyadurai R. Cutaneous botryomycosis of the foot: A case report and review of literature. Indian J Med Microbiol. 2018;36(3):447-9. Available from: https://doi.org/10.4103/ijmm.IJMM_18_347.
https://doi.org/10.4103/ijmm.IJMM_18_347...
. Histopathology can demonstrate the Splendore-Hoeppli phenomenon, but it is not pathognomonic, as it occurs in other infectious and non-infectious diseases33. Hussein MR. Mucocutaneous Splendore-Hoeppli phenomenon. J Cutan Pathol. 2008;35(11):979-88. Available from: http://doi.org/10.1111/j.1600-0560.2008.01045.x.
https://doi.org/10.1111/j.1600-0560.2008...
. Thus, a culture of biopsied tissue is fundamental for diagnosis11. Eyer-Silva WA, Silva GARD, Ferry FRA, Pinto JFDC. Facial botryomycosis-like pyoderma in an HIV-infected patient: remission after initiation of darunavir and raltegravir. Rev Soc Bras Med Trop. 2017;50(2):277-9. Available from: https://doi.org/10.1590/0037-8682-0061-2016.
https://doi.org/10.1590/0037-8682-0061-2...

2. John K, Gunasekaran K, Kodiatte TA, Iyyadurai R. Cutaneous botryomycosis of the foot: A case report and review of literature. Indian J Med Microbiol. 2018;36(3):447-9. Available from: https://doi.org/10.4103/ijmm.IJMM_18_347.
https://doi.org/10.4103/ijmm.IJMM_18_347...
-33. Hussein MR. Mucocutaneous Splendore-Hoeppli phenomenon. J Cutan Pathol. 2008;35(11):979-88. Available from: http://doi.org/10.1111/j.1600-0560.2008.01045.x.
https://doi.org/10.1111/j.1600-0560.2008...
.

REFERENCES

  • 1
    Eyer-Silva WA, Silva GARD, Ferry FRA, Pinto JFDC. Facial botryomycosis-like pyoderma in an HIV-infected patient: remission after initiation of darunavir and raltegravir. Rev Soc Bras Med Trop. 2017;50(2):277-9. Available from: https://doi.org/10.1590/0037-8682-0061-2016.
    » https://doi.org/10.1590/0037-8682-0061-2016
  • 2
    John K, Gunasekaran K, Kodiatte TA, Iyyadurai R. Cutaneous botryomycosis of the foot: A case report and review of literature. Indian J Med Microbiol. 2018;36(3):447-9. Available from: https://doi.org/10.4103/ijmm.IJMM_18_347.
    » https://doi.org/10.4103/ijmm.IJMM_18_347
  • 3
    Hussein MR. Mucocutaneous Splendore-Hoeppli phenomenon. J Cutan Pathol. 2008;35(11):979-88. Available from: http://doi.org/10.1111/j.1600-0560.2008.01045.x.
    » https://doi.org/10.1111/j.1600-0560.2008.01045.x

Publication Dates

  • Publication in this collection
    25 Feb 2022
  • Date of issue
    2022
Sociedade Brasileira de Medicina Tropical - SBMT Caixa Postal 118, 38001-970 Uberaba MG Brazil, Tel.: +55 34 3318-5255 / +55 34 3318-5636/ +55 34 3318-5287, http://rsbmt.org.br/ - Uberaba - MG - Brazil
E-mail: rsbmt@uftm.edu.br