LAUSR

Dear Editor, Botryomycosis is a chronic, granulomatous, suppurative, and rare infection, affecting mainly the skin, but can also reach subcutaneous and deep tissues. Although the etiology of the term implies a fungal infections, botryomycosis is caused by bacteria, and the most frequent infecting species is Staphylococcus aureus. Botryomycosis begins when bacteria accesses the skin through trauma or surgical wounds. Immunocompromised individuals are particularly at risk, but immunocompetents can also be infected. In general, the hands, feet, head, and neck are the main affected areas of the body. In the present work, we describe a patient with botryomycosis, caused by multidrug resistant S. aureus, with previous history of pituitary microadenoma. Male patient, mixed race, 18 years old, showing increased volume of fibrotic tissue, multiple fistulas with spontaneous draining of white secretion and deep nodes in the fingers and in the back of both hands (Figure 1A). He works with agriculture, cultivating palm trees, that can result in perforating traumas. On February 2014, he was admitted in the Endocrinology service of Clinics Hospital due to Cushing syndrome that was secondary to the pituitary microadenoma, which was excised via a transsphenoidal procedure; after this surgery Cushing syndrome was controlled. Simultaneously, lesions in the hands were observed. Biopsy, direct examination, and culture of the skin lesion from the fourth left finger was carried out. Ultrasonography (USG) and radiography of the hands were performed, and USG-guided aspirate from the skin lesion was collected to identify the etiologic agent. HIV serology was also performed. Differential diagnosis was performed with eumycetoma, actinomycetoma, and pseudomycetoma. Histologically, fistulosis dermatitis with grains containing roundshape structures was observed along with Splendore-Hoeppli phenomenon (Figure 2). Skin sections, stained by Grocott and Gram stains, did not present grains, suggesting botryomycosis. Fungi and anaerobic bacteria species were found to be negative in direct search and in culture mediums. Bacterioscopic examination showed rare gram-positive cocci, isolated and in pairs; biopsies were positive for S. aureus, resistant to penicillin, erythromycin, and clindamycin. USG of the hands showed many nodular hypoechogenic formations, with regular shape that occupied the subcutaneous space; some of them in contact with tendons. Radiography of the hands did not show signs of osteomyelitis; patient was negative for HIV infection. Partial recovery was verified during the treatment with sulfamethoxazole and trimethoprim (320 and 1600 mg/d/3 mo, respectively), treatment was maintained until healing (6 months), with half dose of each antibiotic (Figure 1B). Over the treatment, it was observed progressive decreasing in the edema; lesions healed and grains were no longer eliminated. Biochemical parameters were normal during treatment. Relapses were not observed. In the present work, a case of botryomycosis was described in a patient with Cushing syndrome due to the pituitary microadenome. This infection was caused by multidrug resistant S. aureus. Infection was diagnosed using lesion morphology, histopathology, and bacteria identification. Histologically Splendore-Hoeppli phenomenon was observed, and although it can be considered an attempted of the host immune system to restrain microbes, S. aureus was able to escape from the immune system, causing botryomycosis in such patient. In