INTRODUCTION
Botryomycosis is a rare chronic bacterial infection of the
skin or viscera that resembles a deep fungal infection
both clinically and histologically. The most commonly
identified pathogen in human infection is Staphylococcus aureus,
a gram-positive cocci, although several other organisms
have been isolated, including Pseudomonas aeruginosa and
Escherichia coli.1 On microscopic examination, there is a central
cluster of bacteria with a surrounding area of eosinophilia,
often resembling the sulfur granules of actinomycosis, referred
to as the Splendore Hoeppli phenomenon.2 Botryomycosis has
two distinct patterns of infection, visceral and cutaneous, the
latter being the most common. Cutaneous botryomycosis involves
the skin, subcutaneous tissues, muscle and bone. The
extremities are the most common areas affected, with lesions
in the trunk, face and perianal area reported less frequently.
Visceral involvement has also been cited, with the lung as the
most common infection.1
CASE REPORT
An 83-year-old African American woman presented with a
2-day history of worsening dyspnea and chest pain, as well
a 1-week history of fever and painful crusted cutaneous lesions.
She reported that multiple pustular lesions appeared
over the course of a week on her face and right arm; several
of which produced purulent drainage. The dyspnea had been
getting progressively worse for a couple months prior to
admission, and she had recently started oxygen supplementation.
The patient had a past medical history of squamous
cell carcinoma of the left lung, treated with chemotherapy and
focused radiation 2 years ago. On presentation, a preliminary
diagnosis of bacterial endocarditis was made by the primary
team. Intravenous vancomycin was started and blood cultures
were drawn. Transthoracic echocardiogram was nondiagnostic,
and transesophageal echocardiogram was deferred due to
the diminished respiratory capacity of the patient. Chest x-ray
revealed an increased opacification of the left upper lobe. CT
scan taken 1 month prior to admission showed a dense matted
consolidation involving the left lobe.
On cutaneous examination, she had multiple small, tender,
erythematous papules involving the right cheek, right upper
eyebrow, left temporal hairline, tip of the nose, right pretibial
area and right forearm, and right eyelid (Figures 1-3). A 3mm
black eschar without surrounding erythema was present on
the right thumb (Figure 4). Three 1cm erythematous papules
with central black eschar were noted on the right forearm. The
right pretibial area showed a 4mm black eschar with 1cm of
surrounding erythema. A small 1mm pustule was seen on the
nasal tip. On the second day of admission the patient noted a
new tender lesion on her left labia majora, which was a 2mm
skin colored tender papule with no discharge or necrotic center.
Bacterial culture was collected from the nasal tip pustule and
biopsies from two lesions on the right forearm were taken for
H&E and tissue cultures. The fresh tissue and nasal tip cultures
consisted of gram-positive cocci arranged in clusters, which
grew out Staphylococcus aureus. The biopsy revealed a dense
and diffuse acute suppurative infiltrate. The center of the biopsy
consisted of numerous bacterial colonies arranged in a
distinctive “bunch of grapes†pattern (Figures 5-6). The blood
cultures and PAS stains were negative.
DISCUSSION
Botryomycosis was first described by Bollinger in 1870, who
noted the numerous granulomatous lesions that appeared
after the castration of horses.1 Bollinger, and later Rivolta in
