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Subcutaneous entomophthoromycosis mimicking soft-tissue sarcoma in

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 Journal of Pediatric Surgery 50 (2015) 1150–1155

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Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Subcutaneous entomophthoromycosis mimicking soft-tissue sarcoma

in children☆
Venkatachalam Raveenthiran a,b,⁎, Vincent Mangayarkarasi c, Murugesan Kousalya c,
Periyaswamy Viswanathan d, Manivachagam Dhanalakshmi d, Viswanathan Anandi e
a
Department of Pediatric Surgery, Sri Ramasamy Memorial (SRM) Medical College, Kattankulathur, Chennai, India
b
Hindu Mission Hospital, Tambaram, Chennai, India
c
Department of Microbiology, SRM Medical College, Kattankulathur, Chennai, India
d
Department of Pathology, Rajah Muthiah Medical College, Chidambaram, India
e
Department of Microbiology, Rajah Muthiah Medical College, Chidambaram, India

a r t i c l e i n f o a b s t r a c t

Article history: Aim: Subcutaneous entomophthoromycosis (EM) is an uncommon fungal infection of childhood. This article is
Received 22 July 2014 intended to draw the attention of pediatric surgeons to the fact that EM can mimic soft-tissue tumor.
Received in revised form 23 September 2014 Methods: It is a retrospective review of 16 children treated for subcutaneous EM between 2000 and 2013.
Accepted 13 November 2014 Results: The median age of patients was 3.5 years. The typical lesion was a discoid subcutaneous mass that can be
easily lifted from deeper tissues (the doughnut lifting sign). Lesions were mostly distributed in the lower half of
Key words:
body. All the patients were immunocompetent. Correct clinical diagnosis was made only in 4 cases while others
Zygomycosis
Phycomycosis
were mistaken for a tumor. All the 8 children who underwent wide excision of the pseudotumor had local recur-
Pseudo-tumor rence. Supersaturated solution of potassium iodide was curative in 11 cases while addition of itraconazole was
Fungal infection needed in one case. One child died of muti-drug resistant infection. The mean treatment duration was 4.7 months
Potassium iodide months (range 2–8 months).
Differential diagnosis Conclusion: Subcutaneous EM can mimic soft-tissue tumor. High index of suspicion is essential to avoid misdiag-
Soft-tissue sarcoma nosis and inappropriate treatment. A newly described “doughnut-lifting sign’ may be helpful in clinical diagnosis.
Basidiobolus Emergence of multi-drug resistant infection is a source of concern.
Conidiobolus
© 2015 Elsevier Inc. All rights reserved.

Entomophthoromycosis (EM) is an uncommon fungal infection
caused by entomophthoromycota [1,2]. The phylum is named so be-
cause the fungi are often used as bio-insecticides (entomo = insect;
phthoro = destroyer). Basidiobolus ranarum and Conidiobolus coronatus
are the two common opportunistic pathogens of this group. Both of
them are saprophytes commonly found in soil and decaying organic
wastes. Accidental inoculation by inconspicuous injuries such as thorn
pricks, scratches, insect bites and contaminated injection-needles may
cause human infections [3]. It was first described from Indonesia in
1956 by Lie Kian Joe who reported 2 children with Basidiobolus infection
[4]. Subsequently, Burkitt published a large series of 31 cases from
Uganda [2]. EM is common in tropical areas such as sub-Saharan
Africa [2], South East Asia [5], and Brazil [6]. However, probably due
to international travels, it is increasingly been reported from non-
endemic areas such as USA [7], Australia [8], Germany [9], Arabian
peninsula [10], Portugal [11] and Netherlands [12].
☆ Parts of the manuscript were read at the 12th annual meeting of Tamilnadu and
Pondicherry Pediatric Surgeons (TPPS) on 28–30 July 2013, Kanyakumari, India. It was
awarded with the “Best Oral Presentation” prize.
⁎ Corresponding author at: 200. Fifth Street Viduthalai Nagar, Sunnambu Kolathur,
Chennai 600117, India. Tel.: +91 94433 10182.
E-mail address: vrthiran@yahoo.co.in (V. Raveenthiran).
EM is predominantly a disease of pediatric age group [2,5]. In
Burkitt’s series 63% of patients were under the age of 9 and 30% were
adolescents while only 7% were adults [2]. The infection is mostly con-
fined to subcutaneous tissue, although, disseminated forms [12–14]
and visceral involvement [10,15] are rarely reported. Even in endemic
areas, subcutaneous EM is frequently mistaken for soft tissue sarcoma
or lymphoma [6,16,17]. Consequently, inappropriate investigations
and delay in treatment are not uncommon. In this paper we narrate
our clinical experience with 16 cases of subcutaneous EM and intend
to draw the attention of pediatric surgeons to the deceptive clinical
presentation of this uncommon but emerging entity.
1. Methods and materials
Between 2000 and 2013 the principal author (VR) was involved in
the management of 17 children suffering from EM at 4 different institu-
tions namely Rajah Muthiah Medical College (Chidambaram),
Dhanvantri Medical Center (Chidambaram), Sri Ramasamy Memorial
Medical College (Chennai) and Hindu Mission Hospital (Chennai).
Clinical details of the patients were retrospectively reviewed. One case
was excluded as the case record could not be retrieved. One case, that
has already been reported elsewhere [18], is included in the study.

http://dx.doi.org/10.1016/j.jpedsurg.2014.11.031
0022-3468/© 2015 Elsevier Inc. All rights reserved.
 V. Raveenthiran et al. / Journal of Pediatric Surgery 50 (2015) 1150–1155 1151

Fig. 1. Difference in the colony morphology of Basidiobolus (A) and Conidiobolus (B). Flat, furrowed, waxy, yellow colonies are typical of Basidiobolus. In contrast, Conidiobolus colonies are
white, buff and powdery with short aerial mycelium.

Diagnosis of EM was accepted if the fungus is demonstrated in
either histology or culture. In addition to the routine Hematoxylin-
eosin (HAE) stained histological preparation, special fungal stains
such as periodic acid-Schiff (PAS), Gomori’s methenamine silver
(GMS) were used selectively. Presence of Splendore-Hoeppli
phenomenon (encasement of fungal hyphae by eosinophilic debris
and eosinophilic leukocytes), presence of characteristic (broad,
aseptate, empty-looking, twisted-ribbon like) fungal hyphae and
absence of vascular invasion were considered diagnostic of EM
[19]. Minced tissue specimens were cultured in Sabouraud’s
dextrose agar medium. Fungal culture became routine only after
2008 before which it was done sparingly when histological diagnosis
was difficult. Lactophenol cotton blue mount was used to study the
fungal morphology. Basidiobolus and Conidiobolus were distin-
guished by their characteristic colony morphology (Fig. 1) and
zygospores (Fig. 2). Serodiagnosis was not practiced. Routine in-
vitro antifungal susceptibility testing was established in 2011 when
a multi-drug resistant case was encountered [20]. All the patients
were screened for immunodeficiency. Periodic thyroid function
tests, estimation of serum electrolytes and electrocardiogram
(ECG) were done in patients receiving potassium iodide treatment.
Orally administered supersaturated solution of potassium io-
dide (SSKI) was the treatment of our choice. The solution (not com-
mercially available) was prepared by hospital pharmacy by
dissolving pure crystals of potassium iodide in warm distilled
water and the solution was dispensed in light-proof glass bottles.
The dosage of SSKI was 30 to 50 mg/kg/day [2,21]. SSKI contains ap-
proximately 47 mg of potassium iodide in each drop [21] Therefore
the rule of thumb for dosage was one drop of SSKI/kg/day. Treat-
ment was started with half the estimated dose (20 mg/kg/day)
and it was gradually increased over the next 4 to 6 days gauging
the child’s tolerance. Patients who received oral SSKI were hospi-
talized for the initial 72 hours to monitor serum potassium levels
and cardiac arrhythmia. Thereafter, home administration of the
drug was continued until the lesion was cured. Therapeutic end-
point was arbitrarily set at 8 weeks beyond complete resolution of
all palpable indurations. Drug resistance was suspected when the
lesion did not show any resolution even after 3 weeks of treatment.

Fig. 2. Morphological difference in the zygospore of Basidiobolus (A) and Conidiobolus (B). Beak-shaped remnants of copulation tubes (arrow) are typical of Basidiobolus. Papilla protruding
from conidia (arrow) is characteristic of Conidiobolus. Lactophenol cotton blue preparation 400×.
1152 V. Raveenthiran et al. / Journal of Pediatric Surgery 50 (2015) 1150–1155
Fig. 3. Subcutaneous Entomophthoromycosis of the right wrist mimicking osteoclastoma.
Periodic surveillance for local or distant recurrences was done for
24 months following the therapeutic endpoint and thereafter pa-
tients were discharged.
2. Results
Case records of 16 patients who suffered from EM were reviewed.
The median age of patients was 3.5 years (Range 12 months to
14 years). There were 10 boys and 6 girls. The size of subcutaneous
Fig. 4. Clinical appearance of subcutaneous Entomophthoromycosis of abdominal wall. (A) Scar of previous wide excision (arrow) along with local recurrence of the mass (arrow heads) is
evident, (B) Doughnut-lifting sign demonstrated in the same patient.
lesions ranged from 1 × 1 cm to 15 × 10 cm. They were distributed in glu-
teus (n = 4), thigh (n = 3), anterior abdominal wall (n = 2),
anterior chest wall (n = 2), low back (n = 2), genitalia (n = 2), wrist
(n = 1), knee joint (n = 1), scapular area (n = 1) and calf (n = 1). All
of them had incidentally noticed painless mass except 3 children who
had painful swelling. One child had intermittent low-grade fever and
poor feeding. Correct clinical diagnosis was made in only 4 of them
while EM was suspected in another 3 children. The commonly mistaken
clinical diagnosis were rhabdomyosarcoma (n = 4), infantile
fibromatosis (n = 2) and osteomyelitis (n = 2). EM was also mistaken
for synovial sarcoma, osteoclastoma (Fig. 3), osteosarcoma, neurofibro-
ma and sacrococcygeal tumor in one case each. A history of antecedent
minor injury was present in only 6 cases. In the remaining cases
parents could not recollect any recognizable injury preceding the onset
of swelling. On initial presentation, 8 of the children who had lesion of
less than 4 cm diameter underwent wide excision aiming cure; but all
of them had local recurrence. Three of them had more than one wide ex-
cision before the correct diagnosis was made (Fig. 4A). The mean delay
between parental cognizance of a swelling and the correct diagnosis
(data available for 15 cases) was 4.6 months (range 1–8 months).
Histologically fungus was demonstrated in 10 patients. Of the
9 fungal cultures Basidiobolus ranarum was isolated in 5 cases,
Conidiobolus coronatus in one and unidentified species in one while 2
did not have any growth.
All the 16 patients received SSKI as initial treatment. There were 3
dropouts during treatment. Eleven of them were cured after mean
treatment duration of 4.7 months (range 2–8 months). One child
required addition of itraconazole for 3 months as the response to
SSKI was slow. In one child SSKI (4 months), itraconazole (1 month),
SSKI + itraconazole (2 weeks), Amphotericin B (3 weeks), intra-
lesional Amphotericin B (2 doses) and co-trimoxazole (2 weeks) could
not control the fungal invasion. The lesion which was originally con-
fined to periumbilical region progressively increased in size to involve
entire anterior abdominal wall, both groin, scrotum and perineum
(Fig. 5). Although multidrug resistance was suspected it could not be
proved by susceptibility testing as it was then unavailable. Spontaneous
ulceration of mass occurred in multiple areas. He died at home 2 weeks
 V. Raveenthiran et al. / Journal of Pediatric Surgery 50 (2015) 1150–1155
Fig. 5. Muti-drug resistant Entomophthoromycosis with extensive local spread in abdom-
inal wall which proved fatal.
after leaving the hospital. After one month of his death, his mother
developed a painless nodule in the left breast. It was diagnosed as EM
and treated successfully by a dermatologist elsewhere (She is not
including in the present series).
Screening for immunodeficiency was negative in all the 16 patients
including the one who died. None of them had any cardiac event or
thyroid dysfunction during SSKI treatment. Four children could not ini-
tially tolerate SSKI due to gastric irritation. They developed nausea,
vomiting and epigastric discomfort. However, adverse effects
settled when SSKI was given along with antacids. Seven patients
who completed a minimum of 2 years follow-up are free of local or
distant recurrences.
3. Discussion
Until recently, terms such as ‘zygomycosis’ [3,6,22] and
‘phycomycosis’ [2,4,17] have been used to refer EM. It is because
Basidiobolus and Conidiobolus were previously included under the
order Entomophthorale which was then a subset of the phylum
Zygomycota (Fig. 6). Phycomycota (phyco = algae) was the primitive
name of Zygomycota. These older terminologies are not only inaccurate
Fig. 6. Comparison of old and new classification emphasizing the change of nomenclature (Zygomycosis vs Entomophthoromycosis).
1153
but also misleading. Recently, Humber re-classified [23] these fungi
based on their molecular phylogeny. According to this new classifica-
tion, Entomophrhoromycota is identified as a separate phylum that is
distinct from Zygomycota. Zygomycota also includes the order
Mucorale. Thus the term ‘zygomycosis’ has been used confusingly to
mean both mucormycosis and EM. But the two entities are dissimilar
in clinical features, pathogenesis and outcome (Table 1). Some authors
have used descriptive names such as ‘Basidiobolomycosis’ [7,12,14]
and ‘Conidiobolomycosis’ [13,24]. In many centers mycological exper-
tise is not readily available for exact genus identification. Further, the
clinical features and treatment of both the fungal infections are
mostly identical that their differentiation is academic rather than of
clinical importance. For these reasons, we prefer - like many other
authors [5,8,11] - the encompassing term ‘entomophthoromycosis’
despite its cumbersome spelling. Basidiobolus meristosporus and
B.haptosporus, which were previously considered as different organ-
isms, are now considered synonymous with B. ranarum [23]. These
changes in nomenclature should be kept in mind while interpreting
older literature.
The mode of inoculation of these fungi is a matter of great specula-
tions. Many authors [3,25] believe in direct subcutaneous inoculations
through trivial injuries such as abrasions or pricks. Others believe that
the fungal spores are primarily inhaled or ingested. Subsequently the
spores are thought to reach subcutaneous plane by hematogenous
route. Phototrophic property of these fungi [26] is hypothesized to facil-
itate subcutaneous localization of the spores. Occasional cases of lung
[15] and gut [7,10] infections support the hypothesis of aerodigestive in-
oculation. In our series only 38% had identifiable incident of potential
transcutaneous inoculation. Therefore, we presume that there can be
more than one mode of inoculation.
Entomophthoromycota is a ubiquitous fungus in tropics that is seen
in soil, excreta of reptiles and frogs, decaying organic wastes, vegetables
and damp wooden planks. Despite this omnipresence it is perplexing as
to why the clinical infection is rare. Only 300 cases of Basidiobolomycosis
[3] and 160 cases of Conidiobolomycosis [24] have been reported world-
wide. It is suggested that subclinical exposure to the fungal antigen could
have resulted in herd immunity. If this hypothesis is true, then interna-
tional travelers visiting endemic areas may be at a higher risk of clinical
infection. Although EM has been reported in immuno compromised indi-
viduals [9], it is perplexing as to why it is predominantly seen in
immuno-competent children. None of our patients had recognizable im-
munodeficiency. One hypothesis assumes that temporary immuno-
suppression as in the case of viral fevers, diarrhea and malnutrition
might predispose invasion of inhaled or ingested fungal spores.
1154 V. Raveenthiran et al. / Journal of Pediatric Surgery 50 (2015) 1150–1155

Table 1
and voriconazole [31] are favored over other antifungals such as
Comparison of Mucormycosis (Zygomycota) and Entomophthoromycosis⁎.
flucytosine and fluconazole [28]. Not infrequently more than one anti-
Mucormycosis Entomophthoromycosis † fungal drug are administered concurrently to achieve cure [22,29,32].
Immune status Immuno-compromised Immuno-competent Recent reports [29,30] suggest that the fungi are increasingly resistant
of patients to a variety of antifungal drugs. In our series, a 15-month-old boy died
Vascular Affinity Yes No
due to extensive abdomino-perineal EM which was multidrug resistant.
of fungus
Tissue Gangrene Frequent & Extensive Nil
SSKI, itraconazole, amphotericin B and co-trimoxazole were tried in se-
Tumor like lesions Never seen Common manifestation quence and combination without any benefit. Posaconazole [30] and
Tissue invasion Usually deep tissues Usually subcutaneous voriconazole [31], which are currently recommended for resistant
Frequently visceral Rarely visceral fungi, was not used because of its non-availability then. We do not
Frequently affected Rhinocerebral Limbs and trunk in
have experience with other rescue drugs, such as dapsone, described
area BB face in CB
Splendore-Hoeppli Absent Present in the literature. Usually, EM has excellent prognosis although fatal in-
phenomenon in fections have been reported especially in immunocompromised pa-
histology tients [12,24]. Mortality is common with visceral [12], facial or
Usefulness of SSKI Nil Yes perineal [2,32] involvement. The child who died in the series had peri-
Use of Amphotericin-B Drug of Choice Frequently Resistant
Role of surgery Aggressive debridement Limited to Biopsy
neal involvement. It leads us to think that superadded bacterial sepsis
is cardinal Extensive excision is rather than the fungus per se could be the cause of death.
counterproductive In conclusion, EM should be considered in the differential
Prognosis Frequently fatal Usually excellent diagnosis of slow growing subcutaneous mass. It should not be
Death is exceptional
mistaken for soft tissue tumors to avoid mismanagements. Increasing
SSKI - Supersaturated solution of potassium iodide. incidence of multidrug resistant strains and clinical fatalities are a
⁎ Until recently the term “zygomycosis” was used to mean both mucormycosis and
source of great concern.
entomophthoromycosis. Older literature should be interpreted with this caution.
†
Entomophthoromycosis includes basidiobolomycosis (BB) and Conidiobolomycosis (CB).

Subcutaneous, mucocutaneous (rhino-facial), pulmonary, gastroin- References

testinal and genitourinary are the five clinical types of EM. Subcutaneous
infection is the most common form that manifests as pseudotumors. The
lesions are characteristically painless, indolent, woody hard and locally
invasive [2,5]. Occasionally metastatic lesions are also reported [12–14].
For these reasons, EM is frequently mistaken for malignant sarcoma or
lymphoma [6,16,17]. In the present series as many as 10 cases (63%)
were clinically mistaken for a malignant tumor. Consequently inappro-
priate surgical operations such as wide excision had been done in 8 pa-
tients. However, unlike sarcoma, EM seldom invades tissues deeper to
subcutaneous fat. Therefore, it grows like a discoid mass and it can be
lifted like a doughnut by insinuating fingers underneath it (the
Doughnut-Lifting Sign) (Fig. 4B). Skin is usually tethered to the mass
and it may be pigmented. Diffuse swelling of limbs may be mistaken
for edema or osteomyelitis; but it never pits on pressure. The lesions
seldom suppurate and hence draining sinuses and spontaneous
ulcerations are unusual in contrast to mycetoma.
Correct diagnosis is usually established by histopathology [19].
However, in 6 of our cases histology was inconclusive showing chronic
non-specific inflammatory reaction. Fungal hyphae could not be
demonstrated in them even with special fungal stains. In such cases
fungal culture is invaluable to clinch the diagnosis. These fungi are
mesophilic (prefers 30–37 °C) and are damaged by grinding in
mortar. Therefore, the tissue specimen should be transported without
refrigeration and it should be cultured by mincing rather than grinding
the biopsy specimen. They are usually fast growers (4–5 days); but
occasionally the growth is delayed for several weeks due to concomitant
antifungal treatment. In such cases serodiagnosis [27] may be useful;
but it is not widely available.
Role of surgery in EM is limited to diagnostic biopsy. Any attempt of
curative excision will be counterproductive as it leads to recurrence
from seeding of fungus into the margins of excision. In the present se-
ries, all the 8 children who underwent primary excision had recurrence.
In 1960 Raper first suggested the therapeutic use of SSKI which was
later verified by others [2,21,22]. Exact fungicidal mechanism of SSKI
is not known. Failure of SSKI to check the fungal growth in-vitro sug-
gests that it may act through activation of neutrophil chemotaxis [21].
Resistance to SSKI was virtually unknown prior to a decade. Even we
had 11 cases of complete cure with SSKI treatment. Amphotericin B is
usually not preferred because the fungus quickly develop resistance
[28,29]. Imidazoles like itraconozole, ketaconazole, posoconazole [30]
[1] Prabhu RM, Patel R. Mucormycosis and entomophthoramycosis: a review of the clin-
ical manifestations, diagnosis and treatment. Clin Microbiol Infect 2004;10(Suppl 1):
31–47.
[2] Burkitt DP, Wilson AM, Jelliffe DB. Subcutaneous phycomycosis: a review of 31 cases
seen in Uganda. Br Med J 1964;5399:1669–72.
[3] Anand M, Deshmukh SD, Pande DP, et al. Subcutaneous Zygomycosis Due to
Basidiobolus ranarum: A Case Report from Maharastra, India. J Trop Med 2010.
http://dx.doi.org/10.1155/2010/950390 [Article ID 950390].
[4] Joe KL, Pohan A, Ni TE, et al. Basidiobolus ranarum as a cause of subcutaneous myco-
sis in Indonesia. AMA Arch Derm 1956;74:378–83.
[5] Maiti PK, Bose R, Bandyopadhyay S, et al. Entomophthoro mycosis in South Bengal
(Eastern India): a 9 years study. Indian J Pathol Microbiol 2004;47:295–7.
[6] Bittencourt AL, Serra G, Sadigursky M, et al. Subcutaneous zygomycosis caused by
Basidiobolus haptosporus: presentation of a case mimicking Burkitt's lymphoma.
Am J Trop Med Hyg 1982;31:370–3.
[7] Vikram HR, Smilack JD, Leighton JA, et al. Emergence of gastrointestinal
basidiobolomycosis in the United States, with a review of worldwide cases. Clin In-
fect Dis 2012;54:1685–91.
[8] Gordon CL, Whiting S, Haran G, et al. Entomophthoromycosis caused by Basidiobolus
ranarum in tropical northern Australia. Pathology 2012;44:375–9.
[9] Wuppenhorst N, Lee MK, Rappold E, et al. Rhino-orbitocerebral zygomycosis caused
by Conidiobolus incongruus in an immunocompromised patient in Germany. J Clin
Microbiol 2010;48:4322–5.
[10] Al-Shanafey S, Al-Robean F, Bin Hussain I. Surgical management of gastrointestinal
basidiobolomycosis in pediatric patients. J Pediatr Surg 2012;47:949–51.
[11] Bento DP, Tavares R, Martins Mda L, et al. Atypical presentation of
entomophthoromycosis caused by Conidiobolus coronatus. Med Mycol 2010;48:
1099–2104.
[12] Berk GE, Noorduyn LA, Ketel RJ, et al. A fatal pseudotumour: disseminated
basidiobolomycosis. BMC Infect Dis 2006;6. http://dx.doi.org/10.1186/1471-2334-
6-140 [Article 140 (4 pages)].
[13] Kimura M, Yaguchi T, Sutton DA, et al. Disseminated human conidiobolomycosis due
to Conidiobolus lamprauges. J Clin Microbiol 2011;49:752–6.
[14] Bigliazzi C, Poletti V, Dell'Amore D, et al. Disseminated basidiobolo mycosis in an
immuno-competent woman. J Clin Microbiol 2004;42:1367–9.
[15] Chetambath R, Deepa Sarma MS, Suraj KP, et al. Basidiobolus: An unusual cause of
lung abscess. Lung India 2010;27:89–92.
[16] Sivaraman, Thappa DM, Hemanthkumar, et al. Subcutaneous phycomycosis mimick-
ing synovial sarcoma. Int J Dermatol 1999;38:920–3.
[17] Thotan SP, Kumar V, Gupta A, et al. Subcutaneous phycomycosis - fungal infection
mimicking a soft tissue tumor: a case report and review of literature. J Trop Pediatr
2010;56:65–6.
[18] Prasad PVS, Elizabeth KP, George RV, et al. Subcutaneous phycomycosis in a child.
Indian J Dermatol Venereol Leprol 2002;68:303–4.
[19] Das P, Vijay MK, Joshi P, et al. Histological identification of Entomophthoromycosis
in biopsy samples is required. Indian J Pathol Microbiol 2014;57:514–6.
[20] Kousalya M, Mangayarkarasi V, Madhavan R, Raveenthiran V. In-vitro susceptibility
test for zygomycetes. Tenth annual meeting of the Society for Indian Human and An-
imal Mycologists. 10–12 January 2014 Coimbatore, India. (Abstract OP021)
[21] Sterling JB, Heymann WR. Potassium iodide in dermatology: A 19th century drug for
the 21st century - Uses, pharmacology, adverse effects, and contraindications. J Am
Acad Dermatol 2000;43:691–7.
 V. Raveenthiran et al. / Journal of Pediatric Surgery 50 (2015) 1150–1155
[22] Ramesh V, Ramam M, Capoor MR, et al. Subcutaneous zygomycosis: report of
10 cases from two institutions in North India. J Eur Acad Dermatol Venereol
2010;24:1220–5.
[23] Humber RA. Entomophthoromycota: a new phylum and reclassification for
entomophthoroid fungi. Mycotaxon 2012;120:477–92.
[24] Choon SE, Kang J, Neafie RC, et al. Conidiobolo mycosis in a young Malaysian woman
showing chronic localized fibrosing leukocytoclastic vasculitis: a case report and
meta-analysis focusing on clinicopathologic and therapeutic correlations with out-
come. Am J Dermatopathol 2012;34:511–22.
[25] Jayanth ST, Gaikwad P, Promila M, et al. The sinus that breeds fungus: subcutaneous
zygomycosis caused by Basidiobolus ranarum at the injection site. Case Rep Infect Dis
2013. http://dx.doi.org/10.1155/2013/534192 [Article number 534192].
[26] Page RM, Brungard J. Phototropism in Conidiobolus, Some Preliminary Observations.
Science 1961;3481:733–4.
View publication stats
1155
[27] Kaufman L, Mendoza L, Standard PG. Immunodiffusion test for serodiagnosing sub-
cutaneous zygomycosis. J Clin Microbiol 1990;28:1887–90.
[28] Guarro J, Aguilar C, Pujol I. In-vitro antifungal susceptibilities of Basidiobolus and
Conidiobolus spp. Strains. J Antimicrob Chemother 1999;44:557–60.
[29] Tondolo JS, de Loreto ÉS, Dutra V, et al. In vitro susceptibility of Conidiobolus
lamprauges recovered from sheep to antifungal agents. Vet Microbiol 2013;
166:690–3.
[30] Peel T, Daffy J, Thursky K, et al. Posaconazole as first line treatment for disseminated
zygomycosis. Mycoses 2008;51:542–5.
[31] Albaradi BA, Babiker AM, Al-Qahtani HS. Successful treatment of gastrointestinal
basidiobolomycosis with voriconazole without surgical intervention. J Trop Pediatr
2014;60:476–9.
[32] Mendiratta V, Karmakar S, Jain A, et al. Severe cutaneous zygomycosis due to
Basidiobolus ranarum in a young infant. Pediatr Dermatol 2012;29:121–3.