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Ganglion of the ankle
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Ganglion of the ankle Margaret Macpherson, M.D.,* Benjamin K . Fisher, M,D., F.R.C.P.(C),* and David Hastings, M . D . , F.R.C.S.(C)** Toronto, Ontario, Canada Ganglia rarely occur on the ankle. We report a case of a ganglion on the medial malleolus, originating from the sheaths of the flexor digitorum longus and tibialis posterior tendons, which posed a diagnostic dilemma for the patient's family physician, for her dermatologist, and for the orthopedic surgeon seen in consultation. Ganglia should be considered in the differential diagnosis of all pefiarticular cystic lesions. (J AM ACAD DERMATOL13:873-877, 1985.)
Ganglia are benign cysts of uncertain cause that occur in the soft tissue around joints or tendon sheaths and, more rare/y, intraosseously or in nerve sheaths.l'l~ The most common site of occurrence is the dorsum of the wrist. 1.2 We describe a case of a ganglion situated on the ankle and originating from the sheaths of the flexor digitorum longus and tibialis posterior tendons. CASE REPORT A 60-year-old woman first noticed an asymptomatic swelling on the medial aspect of her right ankle in November, 1982. Her family physician withdrew fluid from the lesion and then injected it with "cortisone" on two occasions, but each time the lesion recurred within a day. There was no history of trauma to the ankle. The patient had had mild osteoarthritis involving the distal interphalangeal joints of her fingers for 3 years. This condition had been treated with salicylates at times of flare. She was otherwise well. Three months after she first noticed the problem, physical examination revealed a 4 x 5-em elongated From the Divisions of Dermatology* and Orthopedics,** The Wellesley Hospital and the University of Toronto Medical School. Reprint requests to: Dr. Benjamin K. Fisher, Suite 326, E. K. Jones Bldg., The Wellesley Hospital, 160 Wellesley St., East, Toronto, Ontario M4Y 1J3, Canada. l"Firooznia H, Golimbu C, Rafii M, Chapnick J: Computerized tomography in diagnosis of compression of the common peroneal nerve by ganglion cysts. Comput Radiol 7:343-345, 1983. #Ve~'berne GHM, Jakomowicz JJ: Intraosseous ganglia. Arch Chir Neerl 31:243-247, 1979.
cystic rrontender fluctuating mass proximal and anterior to the medial malleolus (Fig. 1). The dermatologist's clinical impression was that the mass was probably a cavernous lymphangioma. Radiographs of the ankle showed no bony abnormality. Repeat films after injection of the lesion with Hypaque contrast medium showed dye tracking down the sheaths of the tibialis posterior and flexor digitorum longus tendons almost as far as the sole of the foot (Fig. 2). Therefore it was believed that the lesion represented a synovial outpouching from the two tendon sheaths, and it was decided to excise the mass. At surgery, the skin overlying the mass was noted to be markedly thinned. Immediately after the skin incision was made, a very thin-walled, bluish sac was encountered. Since it was not possible to excise the sac, it was perforated, on which maneuver clear, thin fluid emanated. A quickly prepared section of a piece of the wall of the sac was reported to represent a "benign cyst wall." The remaining cyst wall was then completely excised (Fig. 3). An area of communication with the tendon sheaths of the tibialis posterior and flexor digitorum longus tendons was identified proximal to the normal flexor retinaculum. This area was split to prevent a ball-valve effect, that is, to prevent fluid from reaccumulating and not being able to flow freely back inside the sheaths. Histologic sections of the excised sac showed a fibrous and fatty tissue framework with areas of organized hemorrhage and mucoid degeneration. These findings were felt to be consistent with a ganglion (Fig. 4). The incision healed uneventfully, despite the marked skin thinning caused by pressure from the underlying 873
874
Macpherson et al
Journal of the American Academy of Dermatology
Fig. 1. Cystic mass lying anterior to right medial mal-
leolus. mass. A year after removal, the patient is well, with no recurrence of the lesion. DISCUSSION
There is surprising disagreement in the literature as to the cause, pathogenesis, and even pathologic features of ganglia. They are defined as localized cystic swellings that contain clear or gelatinous fluid and that often communicate with and are always adjacent to a tendon sheath or the capsule of a joint. 1 In fact, whether ganglia do or do not communicate with joint cavities has been a matter of considerable dispute, it has been more generally accepted that communications with joint cavities exist since the work o f Andren and Eiken, 3 who performed carpal arthrography in forty-nine patients with wrist ganglia and demonstrated in forty of them a connection between joint and cyst by means of tortuous ducts through the joint capsule. Histologically, the wall of a ganglion consists
Fig. 2. Contrast medium filling ganglion and tracking down sheaths of flexor digitorum longus and tibialis posterior tendons to sole of foot.
of fibrous tissue with a varying number of fibroblasts. Areolar tissue surrounds the wall} A synovial lining membrane may or may not be present; it is believed that with enough fluid pressure buildup inside the ganglion, synovial lining that may exist will atrophy and disappear. A distinction is generally made between ganglia and synovial cysts, with the latter term being reserved for structures formed by herniation of synovial membrane through the joint capsule or enlargement of an anatomic bursa communicating with the joint. 4'* There seems to be some lack of clarity in this distinction of usage, however, since ganglia may have a synovial lining, and it is pos*FomassierV (Department of Pathology,Princess Margaret Hospital, Toronto, Canada): Personal communication, March 20, 1984.
Volume 13 Number 5, Part 2 November, 1985
tulated that they may be formed by herniation of synovial membrane within joints. Some authors appear to use the terms more or less interchangeably? There is as yet no firm consensus concerning the pathogenesis of ganglia. The two main theories are that these lesions result from synovial membrane herniation from within joints or tendon sheaths or from mucinous degeneration of periarticular connective tissue.* Other hypotheses that have been put forward include inspissation of synovial fluid from joint or tendon sheath rupture, retention cysts of subsynovial crypts, distension of anatomic or adventitious bursae, new growth of synovial membrane lining joints or tendon sheaths, and metaplasia of periarticular connective tissue cells with pseudo joint cavity formation. 2'~ de Haas and van Heerde 6 have recentIy reformulated the latter hypothesis, suggesting that adult fibroblasts retain pluripotential (atavistic) arthrogenic properties and may react to injury and to inflammatory or oncogenic stimuli by forming periarticular joint-like structures, such as ganglia, meniscal cysts, synovial cysts, synovial sarcoma, and subcutaneous nodules. It is generally agreed that ganglia are more common in women than men and that onset tends to occur between 10 and 40 years of age. 7 The commonest site of ganglia is the dorsum of the wrist. "-'8 They very rarely occur on the ankle. McEvedy, 2 in his classic paper on ganglia, which deals with their incidence, histologic features, and therapy, compared the sites of ganglia in four series of cases. Ganglia of the ankle accounted for 1%, 4%, 3%, and 0% of cases in series of 255, 150, 58, and 50, respectively, or 2% of the total number of cases. No one seems to have suggested a reason that ganglia should develop so infrequently on the ankle in comparison with the wrist. However, Calberg, 7 in a personal series of twentythree ganglia of the wrist and hand, noted that patients very often reported having to make a stldden and sustained effort of the wrist in the 24 hours preceding the appearance of the lesion. If trauma of this nature is involved in the development of *Fomassier V (Department of Pathology, Princess Margaret Hospital, Toronto, Canada): Personal communication, Match 20, 1984,
Ganglion of the ankle 875
Fig. 3. Wall of cyst lying on surgical drape, following excision. some ganglia, this would help explain why they appear less frequently on the ankle than on the wrist. Ganglia can have various presentations and clinical manifestations. They usually present as periarticular cystic masses and are often symptomless. Our patient had no subjective complaints, but she was noted to have thinning of the overlying skin, most likely because of pressure from beneath. McEvedy z observed that patients with wrist ganglia often report mild aching of the area and a feeling of weakness of the wrist, which he believed to be due to interference by the ganglion with movement of the tendons crossing the joint. Ganglia have been reported to cause various nerve compression syndromes. The median or ulnar nerves may be compressed at the wrist, the ulnar nerve at the elbow, and the common peroneal nerve at the neck of the fibula. 2"~'* Tarsal tunnel *Firooznia H, Golimbu C, Rafii M, Chapnick J: Computerized tomography in diagnosis of compression of the common peroneal nerve by ganglion cysts. Comput Radiol 7:343-345, 1983.
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Journal of the American Academy of Dermatology
Macpherson et al
Fig. 4. Histologic features o f cyst wall. Loose and compact fibrous tissue with blood vessels and areas o f hemorrhage. (Hematoxylin-eosin stain; original magnification, x 40.)
syndrome caused by ganglion compression has also been reported. 5'~° This entity is caused by entrapment of the tibial nerve beneath the flexor retinaculum of the ankle, the symptoms of which are paresthesia and burning pains of the medial heel, sole, and plantar and dorsal aspects of the first and second toes? Our patient did not have these symptoms because her ganglion did not compress the posterior tibial neurovascular bundle in the confined space of the tarsal tunnel. There are a few descriptions of the occurrence of ganglia within nerve sheaths, a phenomenon that often causes nerve compression symptoms.* Again, there is disagreement as to whether these lesions actually arise within the nerve sheath or whether they arise from the joint capsule and dissect into the nerve sheath. Rarely, ganglia pathologically identical to those found in soft tissue may occur intraosseously. These may be inapparent or may be associated with swelling or pain.? Injection of contrast material appears to be a commonly used method of confirming the diag*Verberne GHM, Jakomowicz JJ: Intraosseous ganglia, Arch Chir Need 31:243-247, 1979. ]'Firooznia H, Golimbu C, Rafii M, Chapnick J: Computerized tomography in diagnosis of compression of the common peroneal nerve by ganglion cysts. Comput Radiol 7:343-345, 1983.
nosis of ganglion. Arthrography may delineate the lesion if there is a communication between the cyst and a joint? '4 Firooznia et al* successfully used computerized tomography (CT) scanning to diagnose a ganglion causing peroneal nerve compression, and they state that this is the diagnostic modality of choice; however, CT scanning appears to be an expensive alternative to simple injection of contrast dye, which is virtually without risk. Although it is possible to inadvertently strike an underlying structure, such as an artery or a nerve, such a mistake is unlikely to occur if careful technic is used. Various treatments have been proposed for ganglia over the years, including excision, aspiration, and injection with sclerosing fluids.2 Surgical excision appears to give the lowest recurrence rates v'~ and therefore is the favored form of therapy. *Firooznia H, Golimbu C, Rafii M, Chapnick J: Computerized tomography in diagnosis of compression of the common peroneal nerve by ganglion cysts. Comput Radiol 7:343-345, 1983. REFERENCES
1. Rains AJH, Ritchie HD, editors: Bailey and Love's short practice of surgery, ed. 18. London, 1981, H.K. Lewis & Co., Ltd., p. 311. 2. McEvedy B: Simple ganglia. Br J Surg 49:585-594, 1962.
Volume 13 Number 5, Part 2 November, 1985
3. Andren L, Eiken O: Arthrographic studies of wrist ganglions. J Bone Joint Surg 53A:299-302, 1971. 4. Burr TB, MacCarter DK, Gelman MI, Samuelson CO: Clinical manifestations of synovial cysts. West J Med 133:99-104, 1980. 5. Kenzora JE, Lenet MD', Sherman M: Synovial cyst of the ankle joint as a cause of tarsal tunnel syndrome. Foot Ankle 3:181-183, 1982. 6. deHaasWH, van Heerde P: Synovialnatureofpathologic periarticular structures, including subcutaneous nodules: Descent from embryonic arthrogenic fibroblasts: A hypothesis. Z Rheumatol 38:318-329, 1979.
Ganglion of the ankle
7. Calberg G: Les kystes synoviaux du poignet et de la main. Acta Ortho Belg 43:212-232, 1977. 8. Nelson CL, Sawmiller S, Phalen GS: Gang/ions of the wrist and hand. J BoneJointSurg54A:1459-14641 i972. 9. Harvey FJ, Bosanouet JS: Carpal tunnel syndrome caused by a simple ganglion. Hand 13:164:166, 1981 .. 10. Matricali B: Tarsal tunnel syndrome caused by ganglion compression. J Neurosurg Sci 24:183-185, 1980. 11. Janzon L, Niechajev IA: Wrist ganglia: Incidence and recurrence rate after operation. Scand J Hast Reconstr Surg 15:53-56, 1981.
Exophiala jeanselmei infection in a postrenal transplant patient Wannasri Sindhuphak, M . D . , Etta MacDonald, M . D . , P h . D . , Elizabeth Head, M.T. (A.S.C.P.), and R. Donald Hudson, M . D . *
Galveston, TX, and Bangkok, Thailand We report a case of Exophiala jeansehnei infection in a postrenal transplant patient. He had verrucous lesions on the thigh and abdomen in which clinical and histologic changes resembled those characteristic of chromoblastomycosis. However, the morphologic features of the fungus seen in the tissue sections made it necessary to diagnose this case as phaeohyphomycosis. The patient was treated successfully by complete excision of the lesion on the abdomen and with oral ketoconazole. (J AM ACAD DERMATOL 13:877-881, 1985.)
Organ transplant patients in general, including renal transplant patients, are m o r e susceptible to various kinds of infections, most of them caused b y organisms traditionally considered to be saprophytes or contaminants. T h e s e opportunistic infections are more difficult to diagnose, run a more Severe prolonged course, and are less responsive to therapy. From the Departmentsof Dermatologyand Microbiology,University of Texas Medical Branch, and the Division of Dermatology,Departmentof InternalMedicine, ChulalongkomUniversityHospital. Reprint requests to: Dr. Wannasri Sindhuphak, Division of Dermatology, Departmentof Medicine, ChulalongkornHospitalMedical School, Bangkok 10500 Thailand. *Current address: 1502 Logan St., Laredo, TX 78040.
We report a case o f Exophiala jeanselmei infection in two separate locations in a postrenal transplant patient. CASE R E P O R T A 35-year-old black man with skin lesions on the thigh and abdomen was referred to the dermatologic service. He had undergone a renal transplant operation approximately 15 months before and was receiving aza-~ thioprine (Imuran) and pre.'tnisone immunosuppressant therapy. One and a half months before his first clinic visit he developed a relatively asymptomatic verrucous plaque on the right anterolateral thigh. This lesion continued to enlarge, and 3 weeks later a similar smaller plaque
877
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Ganglion of the ankle Margaret Macpherson, M.D.,* Benjamin K . Fisher, M,D., F.R.C.P.(C),* and David Hastings, M . D . , F.R.C.S.(C)** Toronto, Ontario, Canada Ganglia rarely occur on the ankle. We report a case of a ganglion on the medial malleolus, originating from the sheaths of the flexor digitorum longus and tibialis posterior tendons, which posed a diagnostic dilemma for the patient's family physician, for her dermatologist, and for the orthopedic surgeon seen in consultation. Ganglia should be considered in the differential diagnosis of all pefiarticular cystic lesions. (J AM ACAD DERMATOL13:873-877, 1985.)
Ganglia are benign cysts of uncertain cause that occur in the soft tissue around joints or tendon sheaths and, more rare/y, intraosseously or in nerve sheaths.l'l~ The most common site of occurrence is the dorsum of the wrist. 1.2 We describe a case of a ganglion situated on the ankle and originating from the sheaths of the flexor digitorum longus and tibialis posterior tendons. CASE REPORT A 60-year-old woman first noticed an asymptomatic swelling on the medial aspect of her right ankle in November, 1982. Her family physician withdrew fluid from the lesion and then injected it with "cortisone" on two occasions, but each time the lesion recurred within a day. There was no history of trauma to the ankle. The patient had had mild osteoarthritis involving the distal interphalangeal joints of her fingers for 3 years. This condition had been treated with salicylates at times of flare. She was otherwise well. Three months after she first noticed the problem, physical examination revealed a 4 x 5-em elongated From the Divisions of Dermatology* and Orthopedics,** The Wellesley Hospital and the University of Toronto Medical School. Reprint requests to: Dr. Benjamin K. Fisher, Suite 326, E. K. Jones Bldg., The Wellesley Hospital, 160 Wellesley St., East, Toronto, Ontario M4Y 1J3, Canada. l"Firooznia H, Golimbu C, Rafii M, Chapnick J: Computerized tomography in diagnosis of compression of the common peroneal nerve by ganglion cysts. Comput Radiol 7:343-345, 1983. #Ve~'berne GHM, Jakomowicz JJ: Intraosseous ganglia. Arch Chir Neerl 31:243-247, 1979.
cystic rrontender fluctuating mass proximal and anterior to the medial malleolus (Fig. 1). The dermatologist's clinical impression was that the mass was probably a cavernous lymphangioma. Radiographs of the ankle showed no bony abnormality. Repeat films after injection of the lesion with Hypaque contrast medium showed dye tracking down the sheaths of the tibialis posterior and flexor digitorum longus tendons almost as far as the sole of the foot (Fig. 2). Therefore it was believed that the lesion represented a synovial outpouching from the two tendon sheaths, and it was decided to excise the mass. At surgery, the skin overlying the mass was noted to be markedly thinned. Immediately after the skin incision was made, a very thin-walled, bluish sac was encountered. Since it was not possible to excise the sac, it was perforated, on which maneuver clear, thin fluid emanated. A quickly prepared section of a piece of the wall of the sac was reported to represent a "benign cyst wall." The remaining cyst wall was then completely excised (Fig. 3). An area of communication with the tendon sheaths of the tibialis posterior and flexor digitorum longus tendons was identified proximal to the normal flexor retinaculum. This area was split to prevent a ball-valve effect, that is, to prevent fluid from reaccumulating and not being able to flow freely back inside the sheaths. Histologic sections of the excised sac showed a fibrous and fatty tissue framework with areas of organized hemorrhage and mucoid degeneration. These findings were felt to be consistent with a ganglion (Fig. 4). The incision healed uneventfully, despite the marked skin thinning caused by pressure from the underlying 873
874
Macpherson et al
Journal of the American Academy of Dermatology
Fig. 1. Cystic mass lying anterior to right medial mal-
leolus. mass. A year after removal, the patient is well, with no recurrence of the lesion. DISCUSSION
There is surprising disagreement in the literature as to the cause, pathogenesis, and even pathologic features of ganglia. They are defined as localized cystic swellings that contain clear or gelatinous fluid and that often communicate with and are always adjacent to a tendon sheath or the capsule of a joint. 1 In fact, whether ganglia do or do not communicate with joint cavities has been a matter of considerable dispute, it has been more generally accepted that communications with joint cavities exist since the work o f Andren and Eiken, 3 who performed carpal arthrography in forty-nine patients with wrist ganglia and demonstrated in forty of them a connection between joint and cyst by means of tortuous ducts through the joint capsule. Histologically, the wall of a ganglion consists
Fig. 2. Contrast medium filling ganglion and tracking down sheaths of flexor digitorum longus and tibialis posterior tendons to sole of foot.
of fibrous tissue with a varying number of fibroblasts. Areolar tissue surrounds the wall} A synovial lining membrane may or may not be present; it is believed that with enough fluid pressure buildup inside the ganglion, synovial lining that may exist will atrophy and disappear. A distinction is generally made between ganglia and synovial cysts, with the latter term being reserved for structures formed by herniation of synovial membrane through the joint capsule or enlargement of an anatomic bursa communicating with the joint. 4'* There seems to be some lack of clarity in this distinction of usage, however, since ganglia may have a synovial lining, and it is pos*FomassierV (Department of Pathology,Princess Margaret Hospital, Toronto, Canada): Personal communication, March 20, 1984.
Volume 13 Number 5, Part 2 November, 1985
tulated that they may be formed by herniation of synovial membrane within joints. Some authors appear to use the terms more or less interchangeably? There is as yet no firm consensus concerning the pathogenesis of ganglia. The two main theories are that these lesions result from synovial membrane herniation from within joints or tendon sheaths or from mucinous degeneration of periarticular connective tissue.* Other hypotheses that have been put forward include inspissation of synovial fluid from joint or tendon sheath rupture, retention cysts of subsynovial crypts, distension of anatomic or adventitious bursae, new growth of synovial membrane lining joints or tendon sheaths, and metaplasia of periarticular connective tissue cells with pseudo joint cavity formation. 2'~ de Haas and van Heerde 6 have recentIy reformulated the latter hypothesis, suggesting that adult fibroblasts retain pluripotential (atavistic) arthrogenic properties and may react to injury and to inflammatory or oncogenic stimuli by forming periarticular joint-like structures, such as ganglia, meniscal cysts, synovial cysts, synovial sarcoma, and subcutaneous nodules. It is generally agreed that ganglia are more common in women than men and that onset tends to occur between 10 and 40 years of age. 7 The commonest site of ganglia is the dorsum of the wrist. "-'8 They very rarely occur on the ankle. McEvedy, 2 in his classic paper on ganglia, which deals with their incidence, histologic features, and therapy, compared the sites of ganglia in four series of cases. Ganglia of the ankle accounted for 1%, 4%, 3%, and 0% of cases in series of 255, 150, 58, and 50, respectively, or 2% of the total number of cases. No one seems to have suggested a reason that ganglia should develop so infrequently on the ankle in comparison with the wrist. However, Calberg, 7 in a personal series of twentythree ganglia of the wrist and hand, noted that patients very often reported having to make a stldden and sustained effort of the wrist in the 24 hours preceding the appearance of the lesion. If trauma of this nature is involved in the development of *Fomassier V (Department of Pathology, Princess Margaret Hospital, Toronto, Canada): Personal communication, Match 20, 1984,
Ganglion of the ankle 875
Fig. 3. Wall of cyst lying on surgical drape, following excision. some ganglia, this would help explain why they appear less frequently on the ankle than on the wrist. Ganglia can have various presentations and clinical manifestations. They usually present as periarticular cystic masses and are often symptomless. Our patient had no subjective complaints, but she was noted to have thinning of the overlying skin, most likely because of pressure from beneath. McEvedy z observed that patients with wrist ganglia often report mild aching of the area and a feeling of weakness of the wrist, which he believed to be due to interference by the ganglion with movement of the tendons crossing the joint. Ganglia have been reported to cause various nerve compression syndromes. The median or ulnar nerves may be compressed at the wrist, the ulnar nerve at the elbow, and the common peroneal nerve at the neck of the fibula. 2"~'* Tarsal tunnel *Firooznia H, Golimbu C, Rafii M, Chapnick J: Computerized tomography in diagnosis of compression of the common peroneal nerve by ganglion cysts. Comput Radiol 7:343-345, 1983.
876
Journal of the American Academy of Dermatology
Macpherson et al
Fig. 4. Histologic features o f cyst wall. Loose and compact fibrous tissue with blood vessels and areas o f hemorrhage. (Hematoxylin-eosin stain; original magnification, x 40.)
syndrome caused by ganglion compression has also been reported. 5'~° This entity is caused by entrapment of the tibial nerve beneath the flexor retinaculum of the ankle, the symptoms of which are paresthesia and burning pains of the medial heel, sole, and plantar and dorsal aspects of the first and second toes? Our patient did not have these symptoms because her ganglion did not compress the posterior tibial neurovascular bundle in the confined space of the tarsal tunnel. There are a few descriptions of the occurrence of ganglia within nerve sheaths, a phenomenon that often causes nerve compression symptoms.* Again, there is disagreement as to whether these lesions actually arise within the nerve sheath or whether they arise from the joint capsule and dissect into the nerve sheath. Rarely, ganglia pathologically identical to those found in soft tissue may occur intraosseously. These may be inapparent or may be associated with swelling or pain.? Injection of contrast material appears to be a commonly used method of confirming the diag*Verberne GHM, Jakomowicz JJ: Intraosseous ganglia, Arch Chir Need 31:243-247, 1979. ]'Firooznia H, Golimbu C, Rafii M, Chapnick J: Computerized tomography in diagnosis of compression of the common peroneal nerve by ganglion cysts. Comput Radiol 7:343-345, 1983.
nosis of ganglion. Arthrography may delineate the lesion if there is a communication between the cyst and a joint? '4 Firooznia et al* successfully used computerized tomography (CT) scanning to diagnose a ganglion causing peroneal nerve compression, and they state that this is the diagnostic modality of choice; however, CT scanning appears to be an expensive alternative to simple injection of contrast dye, which is virtually without risk. Although it is possible to inadvertently strike an underlying structure, such as an artery or a nerve, such a mistake is unlikely to occur if careful technic is used. Various treatments have been proposed for ganglia over the years, including excision, aspiration, and injection with sclerosing fluids.2 Surgical excision appears to give the lowest recurrence rates v'~ and therefore is the favored form of therapy. *Firooznia H, Golimbu C, Rafii M, Chapnick J: Computerized tomography in diagnosis of compression of the common peroneal nerve by ganglion cysts. Comput Radiol 7:343-345, 1983. REFERENCES
1. Rains AJH, Ritchie HD, editors: Bailey and Love's short practice of surgery, ed. 18. London, 1981, H.K. Lewis & Co., Ltd., p. 311. 2. McEvedy B: Simple ganglia. Br J Surg 49:585-594, 1962.
Volume 13 Number 5, Part 2 November, 1985
3. Andren L, Eiken O: Arthrographic studies of wrist ganglions. J Bone Joint Surg 53A:299-302, 1971. 4. Burr TB, MacCarter DK, Gelman MI, Samuelson CO: Clinical manifestations of synovial cysts. West J Med 133:99-104, 1980. 5. Kenzora JE, Lenet MD', Sherman M: Synovial cyst of the ankle joint as a cause of tarsal tunnel syndrome. Foot Ankle 3:181-183, 1982. 6. deHaasWH, van Heerde P: Synovialnatureofpathologic periarticular structures, including subcutaneous nodules: Descent from embryonic arthrogenic fibroblasts: A hypothesis. Z Rheumatol 38:318-329, 1979.
Ganglion of the ankle
7. Calberg G: Les kystes synoviaux du poignet et de la main. Acta Ortho Belg 43:212-232, 1977. 8. Nelson CL, Sawmiller S, Phalen GS: Gang/ions of the wrist and hand. J BoneJointSurg54A:1459-14641 i972. 9. Harvey FJ, Bosanouet JS: Carpal tunnel syndrome caused by a simple ganglion. Hand 13:164:166, 1981 .. 10. Matricali B: Tarsal tunnel syndrome caused by ganglion compression. J Neurosurg Sci 24:183-185, 1980. 11. Janzon L, Niechajev IA: Wrist ganglia: Incidence and recurrence rate after operation. Scand J Hast Reconstr Surg 15:53-56, 1981.
Exophiala jeanselmei infection in a postrenal transplant patient Wannasri Sindhuphak, M . D . , Etta MacDonald, M . D . , P h . D . , Elizabeth Head, M.T. (A.S.C.P.), and R. Donald Hudson, M . D . *
Galveston, TX, and Bangkok, Thailand We report a case of Exophiala jeansehnei infection in a postrenal transplant patient. He had verrucous lesions on the thigh and abdomen in which clinical and histologic changes resembled those characteristic of chromoblastomycosis. However, the morphologic features of the fungus seen in the tissue sections made it necessary to diagnose this case as phaeohyphomycosis. The patient was treated successfully by complete excision of the lesion on the abdomen and with oral ketoconazole. (J AM ACAD DERMATOL 13:877-881, 1985.)
Organ transplant patients in general, including renal transplant patients, are m o r e susceptible to various kinds of infections, most of them caused b y organisms traditionally considered to be saprophytes or contaminants. T h e s e opportunistic infections are more difficult to diagnose, run a more Severe prolonged course, and are less responsive to therapy. From the Departmentsof Dermatologyand Microbiology,University of Texas Medical Branch, and the Division of Dermatology,Departmentof InternalMedicine, ChulalongkomUniversityHospital. Reprint requests to: Dr. Wannasri Sindhuphak, Division of Dermatology, Departmentof Medicine, ChulalongkornHospitalMedical School, Bangkok 10500 Thailand. *Current address: 1502 Logan St., Laredo, TX 78040.
We report a case o f Exophiala jeanselmei infection in two separate locations in a postrenal transplant patient. CASE R E P O R T A 35-year-old black man with skin lesions on the thigh and abdomen was referred to the dermatologic service. He had undergone a renal transplant operation approximately 15 months before and was receiving aza-~ thioprine (Imuran) and pre.'tnisone immunosuppressant therapy. One and a half months before his first clinic visit he developed a relatively asymptomatic verrucous plaque on the right anterolateral thigh. This lesion continued to enlarge, and 3 weeks later a similar smaller plaque
877