By Jeong Hwan Kim, MD

Four months ago, I met a 57-year-old patient who had swelling on dorsal side of his third metacarpophalangeal joint. He was healthy and there was no trauma history. He said that he felt swelling on his hand over 10 years ago. He visited several hospitals and was told he had inflammation on his hand, and received several injections. After injection, the symptom was relieved slightly, so he did not mind this symptom as much. Yet the symptoms continued to occur, so he visited one of the most famous dermatologists, and got a needle biopsy. The result of needle biopsy confirmed vascular malformation, he was referred to our hospital for excision of the mass.

 MRI showed 14*13 mm non-enhancing lesion with soft tissue edema and enhancement of third MCP dorsal subcutaneous layer. We performed an excisional biopsy under local anesthesia. There was a gray-colored mass-like lesion with severe adhesion between subcutaneous tissue and third extensor tenosynovium. The mass-like adhesive lesion involved dorsal capsule of MCP joint and 3^rd sagittal band partially. I removed all the adhesive lesion and repaired dorsal capsule and 3^rd sagittal band. A few days later, our pathologist called to me and said that there were many yeast-form fungal organisms, such as Cryptococcus or Coccidioides. Final pathologic report confirmed chronic granulomatous inflammation with fungal infection. Hand surgeon, pathologist, and physician for infectious disease discussed about the result, and we concluded the lesion was a cryptococcal infectious lesion. He was prescribed oral fluconazole more than 3 months ago and there has been no relapse of symptom yet. We will report this unusual case as a case report after 6-month anti-fungal treatment and follow-up MRI.

Jeong Hwan Kim, MD
Department of Orthopedic Surgery, Seoul Medical Center, Seoul, Korea