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A 40-year-old colombian female patient, allergic to non-steroidal anti-inflammatory drugs and with no other relevant medical history, attended the emergency department at a tertiary care hospital of Barcelona, Spain in 2020, due to a 4-day mucocutaneous eruption without associated fever. She had presented with a similar self-resolving symptoms two years prior, which was diagnosed as chickenpox. She did not take any medication and denied having had a herpes outbreak or had any other infections in the previous few weeks. On examination, she presented with multiple targetoid erythematous-violaceous circular plaques on the thorax, arms and back of the hands, some with a central vesicle [Figure 1]. The oro-genital mucosa showed painful haemorrhagic crusts and erosions [Figure 2]. Open in a separate window Figure 1 Photograph of the hands of a 40-year-old female patient showing classic lesions of erythema multiforme manifesting a targetoid appearance with quasi-vesiculation, distributed on the dorsal aspects of both hands. Open in a separate window Figure 2 Photograph of the face of a 40-year-old female patient showing erosions and thick haemorrhagic crusting of the vermilion lips and the perioral region. Erythema multiforme (EM) was suspected clinically. A skin biopsy was performed and treatment was started with a tapered dosage of prednisone, topical methylprednisolone (1 mg/g) and ebastine (10 mg/12 hours). The biopsy showed vacuolar degeneration of the basal layer of the epidermis and spongiosis with isolated colloid bodies corresponding to an interface dermatitis. Direct immunofluorescence showed fibrinogen deposits within the basement membrane and immunoglobulin (Ig)G, IgA, IgM and fraction C3 within the intraepidermal colloid bodies. Both results supported the diagnosis of EM. After two weeks, the lesions resolved, leaving residual hyperpigmentation. The patient in this manuscript has given written informed consent for publication purposes of their case details.

A 70-year old male patient presented to a tertiary care hospital in Amman, Jordan, in 2020 complaining of generalised lymphadenopathy in the neck, axilla and groin. There were no B symptoms, focal signs of infection or palpable spleen. Serologic tests for viral hepatitis and HIV were negative and the serum lactate dehydrogenase level was normal. The patient underwent excisional biopsy of cervical lymph nodes. Microscopic examination revealed effacement of the architecture by myriads of variable-sized follicles. The follicles were crowded, lacked the normal polarisation pattern and the presence of tingible-body macrophages and showed permeation of the lymph node capsule. The inter-follicular area was expanded by small cleaved lymphocytes. The follicles were composed of numerous centrocytes and a moderate amount of centroblasts [Figure 1]. An immunohistochemical study showed the follicles were positive for cluster of differentiation (CD)20, paired box (PAX)5, B-cell lymphoma (Bcl)2, Bcl6 and CD10. CD21 highlighted irregular follicular dendritic cell (FDC) meshwork inside the follicles. The overall features were diagnostic of grade-II follicular lymphoma. It should be noted that most of the neoplastic follicles exhibited one or more Warthin-Finkeldey cells (WFC). On low-power microscopic view, they appeared as dark, hyperchromatic cells, mainly located at the periphery of follicles and occasionally in the centre. The number of nuclei ranged from three to as many as 16. The nuclei were round, larger than lymphocytes and exhibited vesicular chromatin and a small central nucleolus. They were arranged in grape- or chain-like patterns. Careful examination of PAX5 immunohistochemical staining showed a negative nuclear reaction in these cells [Figure 2]. Open in a separate window Figure 1 Haematolxylin and eosin stains at(A)×200 magnification (low-power view; inset at ×1,000 magnification) and(B & C)×600 magnification (high-power views) showing neoplastic follicles that are predominantly composed of small cleaved cells and lack tingible-body macrophages, characteristic of follicular lymphoma. The presence of peripherally and centrally located Warthin-Finkeldey cells should be noted (black circles). Open in a separate window Figure 2 A:Cluster of differentiation (CD)21 immunohistochemical stain at ×200 magnification showing follicular dendritic cells in the neoplastic follicle and the membranous positivity in Warthin-Finkeldey cell (WFC; inset at ×600 magnification).B:PAX5 immunohistochemical stain at ×200 magnification showing a positive result in the nuclear pattern in neoplastic lymphocytes but a negative result in WFCs (inset at ×400 magnification).C:CD3 immunohistochemical stain at ×400 magnification highlighting reactive T-lymphocytes but a negative result in WFCs. Black circles indicate the WFC.

An 80-year-old female patient presented to the Emergency Department of the All India Institute of Medical Sciences, Bhubaneswar, in 2016 with sub-acute intestinal obstruction features. There was no history of surgery, diabetes, hypertension or previous exposure to tuberculosis. A multidetector row computed tomography (MDCT) with an angiography showed a cluster of mild dilated small bowel loops containing air-fluid levels on the right side of the abdomen. Engorged and crowded vessels were seen in the pedicle. The vessels converged at the hernia entrance with a twisted vascular pedicle [Figures 1A, 1B and ​and2A2A]. Open in a separate window Figure 1 Contrast-enhanced multi-detector row computed tomography images of the abdomen of an 80-year-old female patient with(A)the axial section image showing a sac-like cluster of dilated small bowel loops (within the circle) and(B)an axial maximum intensity projection image showing engorged and crowded vessels in the vascular pedicle (arrow). Open in a separate window Figure 2 A:Axial maximum intensity projection of the abdomen with angiography of an 80-year-old female patient during contrast-enhanced multi-detector row computed tomography showing twisting of the vascular pedicle with engorged vessels (arrow).B:Axial section image of the abdomen of a 56-year-old female patient during contrast-enhanced multi-detector row computed tomography showing a cluster of dilated small bowel loops (arrow). Another case of a 56-year-old female patient, who had undergone a hepaticojejunostomy for a post laparoscopy common bile duct injury six years back, presented to the Emergency Department of the All India Institute of Medical Sciences, Bhubaneswar, in 2017 with features of intestinal obstruction. There was no other significant medical history. MDCT angiography showed a cluster of mild dilated small bowel loops in the mid-abdomen without features of bowel ischemia. Twisting of the vascular pedicle (whirlpool sign) was suggestive of volvulus [Figures 2B and ​and33]. Open in a separate window Figure 3 Axial maximum intensity projection of the abdomen with angiography of a 56-year-old female patient during contrast-enhanced multi-detector row computed tomography showing twisting of the vascular pedicle (arrow). Defect closure with repositioning of the bowel loops and fixation of the mesentery was done surgically with uneventful postoperative recovery in both patients. Both patients were doing well during follow-up. Consent was obtained from both patients for publication purposes.

Most lipomas are slow-growing soft tissue tumours that rarely reach 2 cm in size. Those reaching more than five cm are called giant lipomas and are an exceedingly rare entity.1 The following is a description of a case of a large intrathoracic lipoma compressing the right lung managed by complete excision through a median sternotomy. A 27-year-old female patient presented to the obstetrics department of a tertiary care hospital in Muscat, Oman, in 2019 with abdominal pain. An abdominal X-ray revealed a space-occupying lesion on the right side of the chest above the diaphragm as an incidental finding. The patient was referred to the cardiothoracic surgery department for assessment and management. A computed tomography scan showed an anterior mediastinal mass extending into the right thoracic cavity [Figure 1]. Magnetic resonance imaging showed a large fat density lesion in the right hemithorax that appeared inseparable from the thymus [Figure 2]. Open in a separate window Figure 1 Computed tomography scans showing(A)coronal and(B)axial views of a huge and well-defined intrathoracic mass in a 27-year-old female. Open in a separate window Figure 2 Magnetic resonance imaging scan showing(A)coronal and(B)axial views of a large fat density lesion at the thymic level appearing inseparable from the thymus in the right hemithorax of a 27-year-old female. The mass was exposed through median sternotomy given that the tumour was arising from the anterior mediastinum. Following sternotomy, the large mass was seen arising from the thymic area and extending into the right pleural cavity above the diaphragm and compressing the right lower lobe of the lung. The tumour grossly appeared as a light-yellow coloured, soft, encapsulated mass with a smooth surface [Figure 3]. It was attached by its pedicle to the thymus, adjacent to the right phrenic nerve. Removed en-bloc along with the thymus gland, the tumour weighed 2.32 kg and measured 38 × 26 × 15 cm in dimensions. A histopathology of the specimen confirmed the diagnosis of benign thymolipoma [Figure 4]. The post-operative period was uneventful and the patient was discharged after four days. Open in a separate window Figure 3 Photograph of a mediastinal mass with an attachment to the thymus in the anterior mediastinum following dissection in a 27-year-old female. Open in a separate window Figure 4 Haematoxylin and eosin stain at ×400 magnification of a mediastinal mass showing islands of unremarkable thymic tissue within a mature adipose tissue of a 27-year-old female patient. Consent was obtained from the patient for the publication of the case and associated images.

A 33-year-old female patient presented to a tertiary care hospital Bhopal, India, in 2019 with complaints of left-sided chest discomfort for four months and progressively increasing shortness of breath for one month. The patient developed hoarseness of voice, chest pain and dysphagia one week before presenting to this hospital. The chest X-ray revealed a large homogenous opacity in the left hemithorax with tracheal and cardiac deviation to the right side [Figure 1A]. A contrast enhanced computed tomography of the thorax revealed a single large heterogeneously enhancing soft tissue mass lesion occupying the entire left hemithorax, measuring 27 × 14.6 × 15.5 cm [Figure 1B]. The lesion had caused a significant mass effect in the form of a gross contralateral mediastinal shift, inferior displacement of the diaphragm, anterior displacement of the spleen, encasement and obliteration of the left pulmonary artery and abutment and displacement of the left subclavian artery, arch of aorta and descending aorta without any luminal narrowing. No obvious bony lytic or sclerotic lesion was noted. Open in a separate window Figure 1 A:Chest radiography showing the left hemithorax (whiteout) and gross contralateral shifting of mediastinal structures andB:Computerised tomography of the thorax (mediastinal window) at level T-5 showing a huge mass lesion virtually replacing the left lung and gross contralateral shifting of mediastinum in a 33-years-old female patient with Askin’s tumour. The mass lesion also shows various necrotic areas interspersed in between. An ultrasonography-guided fine needle aspiration cytology of the lesion revealed a malignant round cell tumour, potentially qualifying as a primitive neuroectodermal tumour (PNET). A biopsy of the lesion revealed malignant round cell tumour [Figure 2A]. Immunohistochemistry of the lesion was positive for cluster of differentiation (CD)99 [Figure 2B]. The lymphoid markers—Wilms’ tumour 1 gene and epithelial membrane antigen—were negative. Apart from CD99 positivity, the characteristic site and morphology of the tumour supported the diagnosis of PNET. No blasts were observed on peripheral blood and bone marrow examination, excluding the possibility of lymphoblastic malignancy. There was also no sign of desmoplasia in the tumour stroma thereby excluding the diagnosis of a desmoplastic small round cell tumour. The patient was started on chemotherapy with a VAC-IE (vincristine, adriamycin, cyclophosphamide followed by ifosfamide and etoposide) regimen on the advice of a multi-disciplinary team. Serum lactate dehydrogenase (LDH) level was at 904 U/L. A bone marrow aspiration and biopsy done for staging purposes revealed hyper cellular marrow with erythroid hyperplasia and mild megalobastosis with no evidence of marrow infiltration by tumour cells. The patient’s performance status as per the Eastern Cooperative Oncology Group scale was 3/5. She received her first cycle of chemotherapy as per protocol and supportive treatment in the form of feeding through a nasogastric tube, analgesics and hydration. On the fourth day post-chemotherapy, the patient developed hypoxemic respiratory failure which was managed with supplemental oxygen and antibiotics. However, her condition worsened over the next few days with the patient succumbing to respiratory failure. Open in a separate window Figure 2 Ultrasonography-guided biopsy showing a hypercellular tumour lying in sheets composed of small, round, hyperchromatic tumour cells with scant cytoplasm in a 33-year-old female patient with Askin’s tumour.A:Haematoxylin and eosin stain at ×200 magnification showing tumour cells that are seen encircling lumen forming rosettes at certain places.B:Immunostaining with cluster of differentiation 99 at ×200 magnification showing tumour cells displaying strong membranous positivity. Consent was obtained from the patient’s husband to utilise her case record and images for publication purposes.

Comment Overall, CVG cases are classified into primary and secondary forms; primary CVG cases are sometimes further subclassified as either non-essential (i.e. those with associated neurological, psychiatric and ophthalmological manifestations) or essential (i.e. those without abnormalities or secondary disorders).1–3 Primary essential CVG is a rare disorder of unknown aetiology which is five times more frequent in men.4 Most cases are sporadic, although hereditary cases have been described. 2 The prevalence of CVG is unknown in most South American countries, including Bolivia; however, a Colombian study indicated the prevalence of CVG to be 5.9% among institutionalised patients.5 Primary essential CVG usually presents in puberty as symmetric scalp folds extending from the vertex to the occiput which cannot be flattened by traction or pressure.1–3 Typically, the folds resemble the brain cortex and extend anteroposteriorly, although they may also occur in a horizontal direction in the occipital region. Biopsies of the folds show normal skin histopathology.1,3 On MRI, CVG has a typical appearance due to the thickening of the skin and subcutaneous tissues, especially with three-dimensional volume rendering.2 Primary essential CVG must be differentiated from secondary CVG. The latter type can manifest in areas other than the scalp and has been associated with different conditions, such as acromegaly and pachydermoperiostosis. 6,7 Furthermore, CVG has been described among patients receiving external-beam whole-brain radiotherapy, vemurafenib and anabolic steroids.8,9 Primary essential CVG may also be associated with certain genetic disorders, like fragile X syndrome.10 Other conditions that may present with CVG include endocrine diseases (i.e. thyroid disease and diabetes mellitus), intracranial and benign scalp tumours, intracerebral aneurysms, internal malignancy, HIV-related lipodystrophy, inflammatory dermatoses and direct cutaneous infiltration in the setting of malignant haematological disease.1,2 In the present case, the patient had a normal karyotype and did not present with any features of other disorders. Apart from the cutaneous scalp lesions, the physical examination was normal. Furthermore, the patient had no medical or family history of genetic diseases; as such, he was diagnosed with primary essential CVG. As the condition is benign, only symptomatic treatment is necessary.2 Careful local hygiene is sometimes recommended in order to avoid secretions, unpleasant odours and pruritus. Surgical treatment is only necessary for aesthetic reasons and ranges from simple excision to tissue expansion and skin grafts, depending on the size and location of the lesions.2

Comment PPLP is an uncommon entity of low prevalence on the clinical spectrum of lichen planus with an incidence rate of 12.9–26%.1 This disease has a male predilection and the average age of onset of 38 years with a range of 9–72 years.2 The absence of the typical polygonal violaceous papules, which were found on the dorsal aspect of both hands of the current patient, is not unusual; on the palms, the fingertips are usually spared.3,4 In general, of localised lichen planus cases become generalised with the average time of evolution estimated to be between 1–4 months.5 Five clinical types of PPLP have been described, namely eczematous, lichenoid, punctate keratotic, ulcerative and psoriasiform, which is the most frequent.1 There are isolated cases that have described the presence of vesicles, petechiae or umbilicated papules.4 Histolopathological studies are crucial to diagnose PPLP. The pathological characteristics of PPLP are shared with those of classic lichen planus. The thickness of the stratum lucidum of palms and soles has its clinical meaning in the absence of the characteristic Wickham’s striae.5 Differential diagnosis should include psoriasis, hyperkeratotic eczema, diffuse keratoderma, keratosis punctata, lichen nitidus, granuloma annulare and secondary syphilis among others.4 A variable response to treatments, including retinoids, PUVA therapy, corticosteroids, methotrexate, cyclosporine and enoxaparin sodium, has been reported.4–6 It is necessary to establish a therapeutic protocol that assesses the risks and benefits of each patient.

A 25-year-old male patient presented to the emergency room (ER) at the Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India, in 2019 with complaints of abdominal pain, distension, vomiting and non-passage of flatus and faeces for two days. The patient had no history of previous surgery, any toxin ingestion or any other congenital abnormalities. On general physical examination, the patient was tachycardic, dehydrated and the systemic examination was unremarkable. On abdominal examination, diffuse tenderness and no guarding with normal bowel movements were recorded. Digital rectal examination revealed an empty rectum with free rectal mucosa. An X-ray of the abdomen revealed a hugely dilated sigmoid colon. Contrast-enhanced computed tomography (CECT) of the abdomen revealed a massively dilated sigmoid colon with a whirl sign, suggestive of sigmoid volvulus. The patient was taken up for emergency laparotomy, as endoscopic decompression facilities were not available. Intraoperatively, the sigmoid colon was found to be extensively dilated; it was twisted around 270 degrees anti-clockwise, with no gangrene or perforation [Figures 1A and 1B]. Open in a separate window Figure 1 Radiological and intra-operative images of sigmoid volvulus of a 25-year-old male patient presenting to the ER at the Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India, in 2019.A:Contrast-enhanced computer tomography of the abdomen showing sigmoid volvulus (solid arrow) compressing the stomach (red arrow).B:Intraoperative image showing dilated sigmoid volvulus. Resection of the redundant sigmoid colon was performed after detorsion followed by an end-to-end anastomosis, with the fashioning of a diverting loop ileostomy. On post-operative day (POD) 1, when the stoma started functioning and bowel sounds returned, the nasogastric tube was removed and the patient was started on oral liquids. On POD 2, the patient developed tachycardia due to dehydration, which was corrected with intravenous fluids. The abdomen was soft and non-distended and the stoma was functioning. On POD 3, persistent tachycardia, multiple febrile spikes and decreased urine output were noted. Furthermore, the patient developed tachypnoea, hypotension, abdominal distension and non-functioning stoma. A nasogastric tube was reinserted, which drained around 4 L of bilious fluid instantaneously. The patient’s electrolytes were within normal limits, but the total leukocyte count was elevated to 20,000 cells per mm3. Arterial blood gas results showed a pH of 7.28, pO2 of 58 mmHg, pCO2 of 21 mmHg, HCO3 of 15mEq/L and SpO2 of 82%. The patient was intubated and put on a mechanical ventilator. Inotropes were started and antibiotics were changed from intravenous ceftriaxone 1 g twice daily with metronidazole 500 mg thrice daily to 2 g of intravenous meropenem twice a day based on blood and exudate culture sensitivity. The patient was not put on any intravenous opioids post-operatively. An X-ray of the abdomen revealed a hugely dilated stomach with few dilated bowel loops [Figure 2A]. Open in a separate window Figure 2 Radiological and intra-operative images of acute gastric dilatation and gastric necrosis in a 25-year-old male patient presented to the ER at the Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India, in 2019.A:Plain abdominal radiograph showing extensively dilated stomach.B:Gastrectomy specimen showing impending perforation. Re-exploration revealed a healthy anastomotic site at the previous sigmoidectomy site. Around 100 ml of turbid fluid was present in the abdominal cavity. The stomach was dilated, with gangrenous patches of 4 × 5 cm on both the anterior and posterior walls of the stomach. Subtotal gastrectomy with gastrojejunostomy was performed [Figure 2B]. It can be hypothesised that the hugely dilated sigmoid volvulus could have led to gastric volvulus either by some tamponade effect or displacement of the stomach, which might have further led to gastric ischemia and necrosis. Post-operatively, the patient was not extubated in the light of severe acidosis and high inotropic support. The patient was shifted to the surgical intensive care unit (ICU), where over a few hours, his acidosis worsened, ionotropic support increased and urine output dropped to nil. However, despite our best resuscitation, the patient could not be salvaged and succumbed to septic shock on POD 5 of sigmoid volvulus resection. Due to logistical reasons, a post-mortem could not be carried out. The postoperative biopsy reports of the sigmoid volvulus and gastrectomy specimen were unremarkable; while the former was descriptive, the latter showed gangrene.

A 56-year-old male patient, known to have hypertension, presented to the Sultan Qaboos University Hospital in 2019 with a six-year history of gradually increasing left eye protrusion associated with reduced vision in the left eye. Ophthalmic examination revealed a significant proptosis in the left eye with an inferior displacement of the globe [Figure 1]. The best-corrected visual acuity was 6/9 and 6/24 in the right and left eye, respectively. Afferent pupillary defect was noted in the left eye, but slit-lamp biomicroscopy was unremarkable on both sides. Dilated fundus examination of the left eye showed an elevated optic disc with hazy borders. Left eye proptosis secondary to retrobulbar mass was the most likely aetiology and a magnetic resonance imaging (MRI) scan was performed. Open in a separate window Figure 1 Photograph of the eyes of a 56 year-old male patient showing the left eye protruding outward (proptotic). The MRI scan showed an oval-shaped retrobulbar intraorbital lesion measuring 3.0 × 2.7 × 3.1 cm (anteroposterior × craniocaudal × transverse) in size, displacing the orbit anteriorly, the optic nerve inferomedially and the superior and lateral rectus muscles peripherally [Figure 2]. The lesion showed high signal intensity in T2- and isointense signal in T1-weighted images with progressive enhancement starting as a patchy enhancement at the late arterial phase with a complete enhancement of the lesion in the delayed images [Figure 3]. Findings were consistent with orbital slow-flow vascular malformation which was likely a cavernous malformation. Open in a separate window Figure 2 Multi-sequential multi-planar magnetic resonance images of the head (orbits with intravenous contrast) of a 56-year-old male patient.A & B:Axial and coronal T2-weighted images showing an oval-shaped lesion (asterisk) in the retrobulbar intraconal space of the left orbit displacing the glob anteriorly (arrowhead), the optic nerve inferomedially (white arrow) and the superior and lateral rectus muscles (red arrows) peripherally. The lesion shows homogenous intermediate to high signal intensity in T2-weighted images.C:Sagittal precontrast T1-weighted image showing that the lesion is isointense to the cerebral cortex (asterisk). Open in a separate window Figure 3 Axial T1-weighted post-intravenous Gadolinium- enhanced images in the(A)late arterial and(B)delayed phase showing progressive enhancement (solid white arrows). The lesion is almost completly enhanced on the delayed images. Informed consent was obtained from the patient for the publication of these images.

A 60-year-old male patient presented to the Department of Surgery, Dr Sampurnanand Medical College in Jodhpur, Rajasthan, India, in 2018, with complaints of back pain for one month (day 0). On examination, a boil of size 3 × 3 cm was observed on his back, at the medial side of the left scapular region. He was prescribed amoxicillin-clavulanic acid at 625 mg three times a day and non-steroidal anti-inflammatory drugs for one week. No microbiological evaluation was requested by the treating surgeon on day 0. The patient presented again on day 5 with complaints of no improvement, and was subsequently hospitalised for three days. Incision and drainage of the wound was done and dressing with antibiotic coverage was given. On day 13, the patient came back again with complaints of no improvement. Wound debridement and dressing was done and the patient was called for follow-up after seven days. The patient once again came in on day 18 with a massive necrotising wound on the back. Debridement of the dead tissue and toileting of the wound was done with antibiotic coverage. The patient was called for another follow-up after seven days. On day 28, the patient presented to the emergency department, febrile and well-oriented to the time, place and person, with an extensive necrotising wound on his back, extending up to the right arm, with a creeping wound margin in his subcutaneous tissue [Figure 1A]. Open in a separate window Figure 1 A:Extensive necrotising wound on the back of a 60-year-old male patient who presented to the Department of Surgery, Dr Sampurnanand Medical College in Jodhpur, Rajasthan, India, in 2018, with complaints of pain on his back for one month.B:Potassium hydroxide mount from the biopsy tissue showing broad aseptate hyphae with wide-angle branching. The patient had no history of diabetes mellitus, hypertension or any other chronic illness. Complete blood counts and blood glucose were within normal range. On examination of the wound, a clinical diagnosis of necrotising fasciitis was made. Differential diagnosis for aetiological agents of mucormycosis, subcutaneous mycosis and entomophthoromycosis were made by the attending surgeon. Necrotic tissue was removed, and a skin biopsy sample was sent for bacterial culture and sensitivity, potassium hydroxide (KOH) examination and fungus culture to the microbiology laboratory. Upon 10% KOH mount examination, hyaline, broad, aseptate fungal hyphae with wide-angle branching were seen [Figure 1B]. A histopathology examination was not performed and based on KOH examination findings, the patient was hospitalised. Treatment of intravenous amphotericin B, 5 mg/kg/day for four weeks, with 5% dextrose was started immediately along with alternate day amphotericin-B-soaked dressing of the wound. Along with the antifungal agent, antibiotic coverage of piperacillin-tazobactam 4.5 g every eight hours was also administered for one week. Bacterial culture was sterile but white cottony fungal growth with aerial mycelia was seen on Sabouraud dextrose agar (SDA) after 48 hours of incubation. A lactophenol cotton blue mount was prepared from the growth on day 33 (five-day-old colony), day 38 (10-day-old colony) and day 43 (15-day-old colony). In the five-day-old colony, only broad aseptate fungal hyphae were seen; in the 10-day-old colony, scanty sporangia were observed; and in the 15-day-old colony, broad aseptate hyphae bearing sporangium with typical funnel-shaped apophysis was observed at 400× magnification [Figure 2]. Open in a separate window Figure 2 A:Fungal colony on Sabouraud dextrose agar showing aerial hyphae filling the culture plate and tube.B:Lactophenol cotton blue mount of the 15-day-old colony showing broad aseptate hyphae with funnel-shaped sporangiospores arising from the foot cell. Sporangiophores were seen to arise from the foot cell. A dark, thick brown structure was observed just below the sporangiophores. The sporangiospores were oblong and 6–8 μm in size. All these features were consistent with Apophysomyces species complex. The culture report was conveyed to the treating surgeon on day 44. Antifungal sensitivity testing was not performed for this isolate. When fresh granulation tissue started to grow at the wound margin, skin grafting was performed by the surgeon. A skin auto-graft was done on day 57. The patient was discharged after three days of skin-grafting and was kept on follow-up for one month. The skin graft healed well and there was no sign of recurrence of fungal infection or secondary bacterial infection. The fungal isolate was identified as Apophysomyces variabilis by internal transcribed spacer region sequencing at the National Culture Collection for Pathogenic Fungi, Chandigarh, India. The GenBank accession number of the nucleotide sequence is {\"type\":\"entrez-nucleotide\",\"attrs\":{\"text\":\"MN317265\",\"term_id\":\"1723592872\",\"term_text\":\"MN317265\"}}MN317265. The patient provided written informed consent before undergoing surgical procedures and provided consent for his case to be reported for scientific purposes.