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Year : 2020  |  Volume : 63  |  Issue : 4  |  Page : 640-641
Granulomatous inflammation by candida presenting as a hard subcutaneous nodule: A rare case report with review of literature

Department of Pathology, Janakpuri Super Specialty Hospital, New Delhi, India

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Date of Submission14-Jul-2019
Date of Decision08-Sep-2019
Date of Acceptance06-Oct-2019
Date of Web Publication28-Oct-2020


Fungal infections are very important infectious causes of granulomatous inflammation. Isolated subcutaneous fungal infections are uncommon and only seen in immunosuppressed patients or in those with other comorbidities. Such cases are usually mistaken as noninfectious benign lesions and fine-needle aspiration cytology (FNAC) can be used for an adequate diagnosis.

Keywords: Candida, fungal infection, granulomatous inflammation, subcutaneous nodule

How to cite this article:
Garg S, Das A, Gulati N, Sinha M. Granulomatous inflammation by candida presenting as a hard subcutaneous nodule: A rare case report with review of literature. Indian J Pathol Microbiol 2020;63:640-1

How to cite this URL:
Garg S, Das A, Gulati N, Sinha M. Granulomatous inflammation by candida presenting as a hard subcutaneous nodule: A rare case report with review of literature. Indian J Pathol Microbiol [serial online] 2020 [cited 2021 May 16];63:640-1. Available from: https://www.ijpmonline.org/text.asp?2020/63/4/640/299312

   Introduction Top

Fungi are important causes of granulomatous inflammation. Subcutaneous fungal infections are localized and present as nontender nodules, hence leading to clinical misdiagnosis of benign noninfectious lesions. The manifestations of subcutaneous fungal infections are a cyst, plaque, ulcer, scaly lesion, verrucous growth, warty plaque, abscess, and keratotic macerated lesions.[1] Abscesses are rare manifestations of C. albicans infection as compared to dermatitis and mucous membrane infection.[2] A review of 301 fungal isolates recovered C. albicans from pus in only one patient.[3] Similarly, another study reported 74 patients with a variety of C. albicans infections; none of them had skin abscess.[4] This is a case of granulomatous inflammation due to candida presenting as hard subcutaneous nodule which was clinically diagnosed as a benign tumor.

   Case History Top

A 68-year-old female presented with a complaint of a nodule in right forehead region [Figure 1]a for two and a half months. No history of trauma, pain or increase in size was seen. She was hypothyroid and had complaints of bilateral knee joint pain and intermittent cough. No history of fever, loss of weight or appetite was noted. Chest X-ray was normal. She was a known case of invasive lobular carcinoma of right breast, pleomorphic variant diagnosed nine years ago. The patient underwent six cycles of chemotherapy and radiotherapy followed by letrozole for a short duration of time and then tamoxifen for eight years. Her routine parameters were normal except for mild anemia and hyperuricemia.
Figure 1: (a) Clinical presentation as a nodule on the forehead (b) Budding yeasts (MGG, 40×). (c) Occasional granuloma (MGG, 40×) (d) PAS positivity in spores (PAS, 40×) (All figures are original)

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On examination, the nodule was hard, nontender, fixed to the deep tissue with free overlying skin. FNA yielded scanty whitish aspirate which on MGG staining showed budding yeast forms of candida [Figure 1]b. No psuedohyphae were visualized. Occasional ill-defined epithelioid cell granulomas [Figure 1]c and numerous multinucleated giant cells were seen. Periodic Acid Schiff stain was positive in fungal spores [Figure 1]d and Ziehl-Neelsen (ZN) stain for acid-fast bacilli was negative. The case was opined as granulomatous inflammation with candida etiology. Repeat fine-needle aspiration cytology (FNAC) was done for culture but as it was a hard nodule, very scanty aspirate was obtained which revealed no growth.

   Discussion Top

Granuloma is characterized by collections of activated macrophages with T-lymphocytes and sometimes associated with central necrosis. The macrophages develop abundant cytoplasm and resemble epithelial cells and are called epithelioid cells.[5]

The causative organisms of a granuloma can be: 1. bacterial 2. metal-induced 3. fungal 4. viral/chlamydial a. cat scratch fever b. lymphogranuloma venereum 5. helminthic 6. foreign body type 7. unknown cause.[6]

In an Indian study, majority of the granulomas were seen in skin and subcutaneous tissues (24.72%), followed by lymph node (21.46%), bones and joints (18.18%), respiratory system (9.46%), gastrointestinal tract (8%), breast (5.8%), male genitourinary system (3.62%), female genitourinary system (2.54%), gall bladder (1.8%), thyroid (1.46%) and rarely in brain and oral cavity. The most common cause of granulomas was tuberculosis (47.26%), followed by leprosy (12.72%), fungal infections (8.72%), foreign body granulomas (8.36%), tumor associated granulomas (5.82%), rhinoscleroma (5.1%), and rarely by actinomycosis, parasitic infestation, and rheumatoid arthritis. The fungal infections identified were aspergillus (25%), followed by rhinosporidiosis (16.6%), cromoblastomycosis (12.5%), pseudolleshcheria boydii, phaeohyphomycosis, mucormycosis and cryptococci (each 8.33%), subcutaneous entomphothormycosis, madura mycosis, and candida (each 4.16%).[6]

Candidemia is a life-threatening infection with high morbidity and mortality especially in patients receiving cancer chemotherapy, immunosuppressive therapy, prolonged antibiotic therapy, neutropenia or hematological malignancies.[7] In a study done in Latin America, cancer was the most frequent underlying condition for candidemia. Co-morbidities like cardiac, neurologic, lung, liver disease, chronic renal failure and diabetes were more frequent in elderly patients.[8]

C. albicans is the most common candida sp. causing infections in humans.[6] Subcutaneous abscess due to C. albicans is described only in patients with other underlying diseases or with lesions of the skin andis a rare complication in the absence of other focal visceral diseases.[7]

For diagnosis, specimen types depend on the site affected and can be:

  • Esophageal brushing
  • Blood
  • Urine and other body fluids
  • Fine-needle aspiration samples
  • Biopsy samples.

As candida is a commensal, isolation from nonsterile specimens has no significance. In blood, urine (collected with aseptic precautions), CSF and sample from closed inflammatory foci, the presence of candida, with any number and any species is pathogenic. Gram stains of smears show gram-positive budding yeasts. Candida on direct microscopy can be seen as extracellular unencapsulated yeasts ± psuedohyphae.[9]

Most commonly used medium for isolation of candida species is Sabouraud Dextrose Agar.[9] But, in our case a repeat aspirate was very scanty, culture on SDA medium revealed no growth. Newer molecular typing methods have included evaluation of genomic DNA by restriction enzyme analysis, electrophoretic karyotyping, and the use of DNA probes.[10]

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Conflicts of interest

There are no conflicts of interest.

   References Top

Priyadharshini G, Varghese RG, Phansalkar M, Ramdas A, Authy K, Thangiah G. Subcutaneous fungal cyst masquerading as benign lesions – A series of eight cases. J Clin Diagn Res 2015;9:EM01-4.  Back to cited text no. 1
Feldman WE, Hedaya E, O'Brien M. Skin abscess caused by candida albicans: Unusual presentation of C. albicans disease. J Clin Microbiol 1980;12:44-5.  Back to cited text no. 2
Szilgyi G, Reiss F. Fubgus infections at Montefiore hospital and medical centre. State J Med 1966;12:3036-9.  Back to cited text no. 3
Mazumdar PK, Marks MI. Candida albicans infections in hospitalized children. Clin Pediatr 1975;14:123-9.  Back to cited text no. 4
Kumar V, Abbas AK, Aster JC. Robbins and Cotran Pathologic Basis of Disease. 9th ed. South Asia: Elsevier 2014; p. 97.  Back to cited text no. 5
Permi HS, Shetty JK, Padma SK, Teerthanath S, Mathias M, Kumar SY, et al. A histopathological study of granulomatous inflammation. NUJHS 2012;2:15-9.  Back to cited text no. 6
Corti M, Villafañe MF, Messina F, Negroni R. Subcutaneous abscess as a single manifestation of Candidiasis. Med Mycol Open Access 2015;1:6.  Back to cited text no. 7
Nucci M, Queiroz-Telles F, Alvarado-Matute T, Tiraboschi IN, Cortes J, Zurita J, et al. Epidemiology of Candidemia in Latin America: A laboratory-based survey. PLoS One 8 2013;8:e59373.  Back to cited text no. 8
WHO. Laboratory manual for the diagnosis of fungal opportunistic infection in HIV/AIDS patients. New Delhi: WHO Regional Office for South-East Asia. 2009; p. 8-11.  Back to cited text no. 9
Fridkin SK, Jarvis WR. Epidemiology of nosocomial fungal infections. Clin Microbiol Rev 1996;9:499-511.  Back to cited text no. 10

Correspondence Address:
Swati Garg
B-1/1041A, Vasant Kunj, New Delhi - 110 070
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJPM.IJPM_555_19

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