Viridans streptococcal endocarditis: the role of various species including pyridoxal dependent streptococci. Rev Infect Dis 1979;1:955-965. 16. Shields MS, Kline BC, Tarn JE: A rapid method for the quantitative measurement of gene dosage: mini-F plasmid concentration as a function of cell growth rate. Journal of Microbiological Methods 1986;6:33-46. 17. Stein DS, Nelson KE: Endocarditis due to nutritionally deficient streptococci: a therapeutic dilemma. Rev Infect Dis 1987;9:908-916. 18. Tuazon

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... CU, Gill V, Gill F: Streptococcal endocarditis: single vs. A patient with severe rheumatoid arthritis treated with prednisone had a painless soft tissue nodule develop on the dorsal aspect of the ring finger. She denied any history of hand trauma, animal exposure, or systemic symptoms such as fever or malaise. Fungal cultures performed on an aseptically obtained aspirate of this lesion demonstrated dark, olive-black creamy colonies on Sabouraud's agar. Slide cultures made from mold colonies produced slender conidial forms with ampliations and spine-like conidiophores, features characteristic of Exophiala spinifera. The lesion was surgically excised, and the patient was successfully treated with a course of oral itraconazole. This nodular lesion has not recurred at the time of this writing. Exophiala species are difficult to differentiate, and E. spinifera may be confused with Exophiala jeanselmei. A literature review will consider Exophiala species and clinical manifestations produced by these dematiaceous fungi. (Key words: Exophiala spinifera; Phaeohyphomycosis; Dematiaceous fungi) Am J Clin Pathol 1989;91: 624-627 DEMATIACEOUS FUNGI are potential pathogens that are present in soil and plant material. They may cause phaeohyphomycoses and mycetomas in humans and animals and are characterized by brown to yellow pigmentation of their cell walls and distinctive black to brown colonial morphologic characteristics. This article reports a case of Exophiala spinifera repeatedly isolated from a soft tissue nodule in a patient with rheumatoid arthritis treated with immunosuppressive agents. A brief literature review of previously reported cases will also be included. Report of a Case A 62-year-old woman complaining of painless induration of her left fourth finger was seen by an infectious disease consultant. The patient noted this lesion had been present for at least three months. She denied any history of hand trauma, animal exposure, nausea, vomiting, fever, or malaise. She had a 40-year history of classic rheumatoid arthritis involving large joints such as wrists, ankles, shoulders, elbows, knees, and hips as well as bilateral small joints of the hands and feet, including proximal and distal interphalangeal joints and metacarpal joints. Eight years before this episode the patient had a surgical synovectomy and replacement of bilateral metacarpal joints with silicone prosthetic implants. Her arthritis was currently being treated with naproxen 500 mg bid, prednisone 2.5 mg qd, and oral gold, 3 mg bid. Physical examination demonstrated decreased range of motion of the large joints, including wrists, elbows, shoulders, hips, knees, and ankles. Swan neck deformities were noted on both hands; rheumatoid nodules were present over extensor surfaces of both elbows. No evidence of active synovitis was noted at the time of consultation. No hepatosplenomegaly was noted, and vital signs were normal. The entire fourth digit of the left hand was edematous and indurated; a boggy nodule approximately 0.5 cm in diameter was present over the dorsum of the left fourth finger between the distal and proximal interphalangeal joints. A small sinus tract opening adjacent to the left distal interphalangeal joint exuded purulent, yellow-white tenacious material. Routine radiographs of the left