Subungual exostosis (SE) is a benign, relatively uncommon bony growth underneath the nails of the distal phalanx of toes or fingers, with a majority on the toes. Clinically, it has two subvariants—protruded and nonprotruded growths from nail plates—which are treated differently. In this article, we report a case of protruded SE in a teenager with illustrative surgical excision. A 15-year-old boy presented with a painful growth on his right great toe of 6 months' duration. Physical examination revealed a 1-cm-diameter, solid, erythematous, rough, irregular growth penetrating through the skin along the dorsolateral nail bed of the right hallux with deformity of the lateral nail plate. Radiographs showed an elevated mass over the distal phalanx of the right lateral hallux. The mass was surgically excised and histopathologic examination confirmed the diagnosis of SE. The patient had no relapse or recurrence at follow-ups of 6 and 18 months. Subungual exostosis is a relatively uncommon bony growth in the toes. Radiography is favored for the diagnosis. Complete surgical excision is the optimal treatment, with rare recurrence. It needs to be differentiated from other bony lesions, including bizarre parosteal osteochondromatous proliferation, myositis ossificans, fibro-osseous pseudotumor, osteochondroma, and enchondroma.
Soft-tissue chondroma is a rare, benign tumor. It is predominantly found in the hands and feet, but rarely in the toes. In this article, we report a digital soft-tissue chondroma that presented as a painful nodule of 5 years' duration in a 67-year-old man. Physical examination revealed a round, solid, movable nodule measuring 7 mm in diameter. Radiographs showed faint linear calcifications in the nodule under the right hallux proximal phalanx neck. The mass was completely excised, and pathologic observation revealed a mass composed of mature chondrocytes in a cartilaginous matrix, consistent with a chondroma. Even though this is a benign tumor, it needs to be differentiated from other tumors, including schwannoma, leiomyoma, chondrosarcoma, and others. Surgical excision is the preferred treatment.
Phaeohyphomycosis is a spectrum of subcutaneous and systemic infections caused by a variety of dematiaceous fungi. It is an opportunistic disease with an increased incidence in immunocompromised patients. We report a case of a pedal phaeohyphomycotic cyst in an immunocompetent adult male immigrant with the goal of highlighting its clinical presentation, diagnosis, and optimal treatment. A 57-year-old male immigrant from Panama presented with a painless, gradually increasing, large cystic lesion in his left foot, first intermetatarsal space, which had been present for many years. The patient was treated with surgical excision without antifungal therapy. Histologic analysis showed multiple granulomas composed of fibrin and necrosis in the centers surrounded by proliferative palisading fibroblasts admixed with heavily infiltrated neutrophils, plasma cells, macrophages, lymphocytes, and eosinophils. Periodic acid-Schiff and Fontana-Masson stains revealed sporadic, scattered dematiaceous fungal hyphae and pseudohyphae among granulomatous tissues. The mass was diagnosed as a phaeohyphomycotic cyst. Polymerase chain reaction–based sequencing failed to identify the fungal species because of the rarity of the fungal elements in the granulomatous tissues. The patient had no recurrence at a follow-up of 2 years. A phaeohyphomycotic cyst is a rare entity that needs to be differentiated from other benign and malignant lesions. Multiple modalities, including clinical evaluation, radiography, histologic analysis, microbiological culture, and nucleic acid sequencing, should be used for the final diagnosis. Surgical excision is an optimal treatment. Antifungal therapy should be considered based on the patient’s clinical manifestation, surgical excision, and immune functional status.
Eumycetoma, caused by fungi, is a neglected tropical disease. It is endemic in the “mycetoma belt” countries but rare in North America. We report a case of pedal eumycetoma in the state of Maryland. A 51-year-old male immigrant from Guatemala presented with multiple, enlarging nodules on the dorsal surface of his left great toe present for 1 year, and a new one in the left arch area present for 6 months. The nodular lesions were surgically excised in two separate operations. Pathologic evaluation of all nodules revealed eumycetomas characterized by the Splendore-Hoeppli phenomenon, showing an amorphous eosinophilic center filled with numerous fungal hyphae, observed on periodic acid-Schiff–stained slides, with a surrounding cuff of neutrophils. Polymerase chain reaction–based sequencing identified Cladosporium cladosporioides in the tissues. The patient was further treated with oral fluconazole for 2 months. The patient recovered well postoperatively and had no recurrence at 20-month follow-up. In conclusion, even though eumycetoma is regarded as a rare disease in North America, its incidence may be higher than reported because of millions of immigrants from endemic regions in the United States, which highlights the need to raise awareness of this devastating disease in the medical community. Eumycetoma needs to be differentiated from other infectious and noninfectious benign and malignant lesions. Optimal treatment includes surgical excision with antifungal therapy.