The patient presented with itchy, grey, scaly, eczematoid lesions of 6 months' duration on the skin of both eyelids (Fig. (Fig.1).1). He was seen previously by dermatologists on three different occasions and was put on topical corticosteroids each time. These relieved the itching and quieted the lesions; however, when the treatment course was completed, the symptoms recurred. The patient was healthy otherwise, and the routine chemical and hematological laboratory investigations were within normal limits. Also, his chest X-ray was normal. Skin scrapings from each of the two lesions were collected. Portions of the scrapings were used for direct microscopic examination in 10% KOH and for culture on Sabouraud dextrose agar (SDA) and on SDA supplemented with 50 μg of chloramphenicol ml⁻¹ (Oxoid Ltd., Basingstoke, England), which were incubated at 26 (±1)°C. The direct microscopic examination of the skin scrapings revealed the presence of branched hyphae (Fig. (Fig.2A),2A), and the cultures grew an unusual dematiaceous mold which was identified as T. pulvinata (Fig. (Fig.2B2B and and3).3). Since the organism was very uncommon, repeat skin scrapings from both lesions were taken and their analysis resulted in the same findings by direct microscopy and culture. Therefore, the patient was treated with topical clotrimazole cream (canesten cream containing 0.01 g of clotrimazole/g of cream; Bayer, Leverkusen, Germany) applied to each of the lesions twice daily for 4 weeks. The lesions resolved considerably after the 2nd week, and a full cure was achieved after the 4th week. No relapse of the infection was observed during a 5-year follow-up.

For identification studies, the isolated fungus was subcultured onto fresh SDA and cornmeal agar media and was incubated at 26 (±1) and 37°C. It grew well on both media and at both temperatures, with moderate growth rates. During the first 3 or 4 days, the colonies appeared creamy and moist. During the next 2 weeks, the centers turned brown and then grey-black as the organism matured (Fig. (Fig.2B).2B). Hyphae were hyaline and thin. Some collected in fascicles or coils on which aggregates of hyaline to light-brown, pyriform, sporogenous cells were formed. The fungus produced three forms of conidia: (i) brown, oval, unicellular conidia; (ii) brown, cylindrical, one-septate conidia; and (iii) hyaline, acicular conidia with 5 or 6 septates tapering to a long break (Fig. (Fig.3).3). It is because of these features that the fungus was identified as T. pulvinata (3, 4). The isolates were preserved in our culture collection under the numbers 4289 and 4989.

Examination of the literature did not reveal any previous report of a human infection caused by this fungus. In fact, not only has organism not been implicated in any infection, the published reports on T. pulvinata itself are very limited. It is not familiar to many mycologists. It sporulates readily, but its identification may not be straightforward because of its pleomorphic nature. All species of the genus Triadelphia are pleomorphic, producing at least two forms of conidia from sporogenous cells that agglomerate in a sporodochium-like aggregate (3, 5). No difficulty was encountered in identifying the present isolates because of previous experience with the fungus (2).

The contribution to this case by Ibrahim Al-Rabieh from our Dermatology Department is acknowledged.