200 An Introduction to Medical Mycology 



seropurulent secretion, which may be increased by pressure of the affected 

 tissues. According to Ormsby, the border of the patches is one of the most 

 characteristic features. This edge is smooth and slopes down abruptly 

 to normal skin. On its surface are minute abscesses, which may be super- 

 ficial or deep seated; when the disease is actively spreading they are pres- 

 ent in large numbers. The hand lens may be required to see these lesions. 

 Puncture of the minute abscesses along the border of a lesion provides the 

 best material for isolation of the organism. Healing occurs first in the 

 central portions of the lesion and is followed by formation of scar tissue. 

 The patches slowly enlarge, and in half the cases (Ormsby) one or more 

 lesions develop in adjacent or remote parts of the skin. 



When systemic dissemination of the organism occurs, any organ or 

 tissue in the body may be attacked. The lungs are the commonest site and 

 often the primary focus; they are affected in over 90 per cent of the cases 

 of systemic involvement. The symptoms at first may be those of an acute 

 infection of the respiratory tract, and a characteristic feature is pain in 

 the chest. Later a syndrome suggestive of tuberculosis is present. The skin 

 may become secondarily infected from deep sites, the organism being 

 carried by the blood stream, in which case subcutaneous abscesses develop. 

 These finally rupture, and one may then note shallow ulcerations, showing 

 granulations at the base, covered with purulent discharge and frequently 

 crusted. When the kidneys become involved, symptoms of nephritis are 

 evident. The bones, particularly the ribs and vertebrae, are frequently 

 affected in the systemic types of the disease, and, according to Stober, the 

 fungus may cause osteomyelitis, periostitis or arthritis. The central nervous 

 system is occasionally involved, and any part of the brain, spinal cord or 

 meninges may become affected. The tongue, the larynx and the intra- 

 abdominal organs have all been reported as occasional sites of the disease 

 but invasion of the intestinal tract is unusual. 



(d) Histology.— Sometimes the pathologic appearance of a visceral 

 lesion suggests tuberculosis. The presence of central necrosis is charac- 

 teristic, and the organism is usually associated with leukocytes, red blood 

 cells and debris. Giant cells of the Langhans type may be noted at the 

 periphery. Granulation tissue usually surrounds the nodule. In the skin, 

 marked and irregular acanthosis is a feature. There are also epidermal 

 abscesses, in which budding yeast cells are associated with the type of 

 cells noted in the center of the visceral nodule just described. A cellular 

 infiltrate and interstitial and parenchymatous edema of the underlying 

 cutis are present. 



(e) Differential diagnosis.— With this, as with other fungous diseases, 

 the causative organism must be demonstrated. Usually this is not difficult 



