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Multiple subcutaneous Candida abscesses on the palm and finger in an immunocompetent patient

Dear Editor, Although disseminated cutaneous candidiasis occurs in 10– 13% of cases of systemic candidiasis and candidemia, primary deep cutaneous candidiasis is uncommon in immunocompetent patients. We describe an immunocompetent patient with multiple subcutaneous abscesses on both hands caused by Candida albicans. A healthy 68-year-old female hairdresser presented in May 2015 with a 30 mm 9 14 mm mass on her left palm (Fig. 1a). She kept a vegetable garden, and had no history of malignancy, diabetes or serious infections. She had had Candida paronychia on the right thumb 5 years prior, and had had thumbnail deformation for at least 3 years. Topical antifungals and corticosteroids were administrated intermittently, but were unsuccessful. No occlusive dressing or taping was applied. Magnetic resonance imaging at an orthopedic hospital revealed a multilobular cystic lesion, which was excised by a hand surgeon (H. T.). Histopathology revealed fungal granuloma in subcutaneous tissue. In October 2015, the patient revisited our clinic with a 20 mm 9 14 mm abscess in the right third finger (white arrow), and a 15 mm 9 10 mm nodule in the proximal part (black arrow) (Fig. 1b). Giemsa staining of punctured pus revealed pseudohyphae and blastoconidia (Fig. 1d). The isolated microorganism formed white to cream-colored, smooth glabrous, yeast-like colonies on Sabouraud’s dextrose agar and showed a distinctive green color on CHROM-agar Candida (Becton Dickinson, Franklin Lakes, NJ, USA). We identified the organism as C. albicans (Robin) Berkhout on conventional mycological studies (morphology and physiology), and the base sequence of the internal transcribed spacer 1 region of the ribosomal RNA gene showed 100% homology (195/ 195 bp) to the C. albicans type strain American Type Culture Collection (ATCC) 18804 (accession no. HQ876043). The minimal inhibitory concentrations of amphotericin B, 5-fluorocytosine, miconazole, fluconazole, itraconazole, micafungin and voriconazole were 0.5, 0.125 or less, 0.25, 0.25, 0.06, 0.06 and 0.015 lg/mL or less, respectively. Histopathology revealed suppurative granuloma and periodic acid-Schiff (PAS)-positive pseudohyphae (Fig. 1e). Moreover, all of her fingernails except that of the right little finger were opaque and thickened (Fig. 1c). Direct microscopy revealed pseudohyphae and acropetal spherical blastoconidia, and histopathological evaluation showed PAS-positive fungal elements (Fig. 1f). The isolates