case_images: PMC3320381_01
case_images: Clinical aspects of the lesion when the patient sought treatment at the University Hospital. The figure depicts the wide extension of the lesion in a frontal (A) and in depth (B) medial views.
case_images: 04-0943-F1.jpg
case_images: PMC3320381_01_04-0943-F1.jpg
case_images: F1
case_images: At admission, the physical examination showed a tibial ulcer 15 cm in diameter with an infiltrating and nodular proximal border (Figure 1).
case_images: Biopsied section of the lesion: A) branch and broad hyphal fragment of Pythium insidiosum (Gomori methemine silver, magnification x200); B) hyphal fragment surrounded by inflammatory cells (hematoxylin and eosin [HE], magnification x200); C) hyphal fragment surrounded by eosinophilic material, which suggests a Splendore-Hoeppli phenomenon (HE, magnification x200).
case_images: 04-0943-F2.jpg
case_images: PMC3320381_01_04-0943-F2.jpg
case_images: F2
case_images: Results of a second biopsy from the border of the ulcer again suggested zygomycosis (Figure 2).
case_images: Slide culture illustrating the broad, branched, and sparsely septate hyphae of Pythium insidiosum (lactophenol cotton-blue, magnification x40).
case_images: 04-0943-F3.jpg
case_images: PMC3320381_01_04-0943-F3.jpg
case_images: F3
case_images: On microscopic examination, slide cultures stained with lactophenol cotton-blue showed broad, branched, and sparsely septated hyphae, without fruiting bodies (Figure 3), which later were identified as colonies of P. insidiosum.
case_images: Polymerase chain reaction with ITS4/ITS5 primers: lane 1, ladder 100 bp; lane 2, positive control showing Pythium brasiliensis band at position 634 bp; lanes 3 and 4, P. insidiosum isolate B01 showing band at position  850 bp.
case_images: 04-0943-F4.jpg
case_images: PMC3320381_01_04-0943-F4.jpg
case_images: F4
case_images: The first round of amplification with the generic primers for fungi (ITS4/ITS5) produced weak bands; in a second round, double PCR, defined and sharp bands of approximately 850 bp were seen (Figure 4).