The Essential Role of PCR and PCR Panel Size in Comparison with Urine Culture in Identification of Polymicrobial and Fastidious Organisms in Patients with Complicated Urinary Tract Infections.

Complicated urinary tract infections (cUTIs) are difficult to treat, consume substantial resources, and cause increased patient morbidity. Data suggest that cUTI may be caused by polymicrobial and fastidious organisms (PMOs and FOs, respectively); as such, urine culture (UC) may be an unreliable diagnostic tool for detecting cUTIs. We sought to determine the utility of PCR testing for patients presumed to have a cUTI and determine the impact of PCR panel size on organism detection. We reviewed 36,586 specimens from patients with presumptive cUTIs who received both UC and PCR testing. Overall positivity rate for PCR and UC was 52.3% and 33.9%, respectively (p < 0.01). PCR detected more PMO and FO than UC (PMO: 46.2% vs. 3.6%; FO: 31.3% vs. 0.7%, respectively, both p < 0.01). Line-item concordance showed that PCR detected 90.2% of organisms identified by UC whereas UC discovered 31.9% of organisms detected by PCR (p < 0.01). Organism detection increased with expansion in PCR panel size from 5-25 organisms (p < 0.01). Our data show that overall positivity rate and the detection of individual organisms, PMO and FO are significantly with PCR testing and that these advantages are ideally realized with a PCR panel size of 25 or greater.

A Subungual Nevoid Melanoma of the Right Hallux from a 65-Year-Old Man: A Case Report.

Nevoid melanoma (NeM) is a rare variant of malignant melanoma characterized by slight cellular atypia, polymorphism, and incomplete maturation. It most frequently occurs on the trunk and arms but rarely on the foot. Here, we report a subungual NeM of the right hallux. A 65-year-old man presented with severe pain of 6 months' duration to his right great toe following self-treatment for an ingrown nail. He was evaluated and treated with debridement of the toenail at an urgent medical center 3 months prior. However, this had not relieved his pain. The patient also noticed discoloration of his distal great toe over the past 3 months. Removal of part of the ingrown nail revealed a pigmented mass extending distally from the matrix. Surgical excision of the mass was performed because of the concern for malignancy. The diagnosis of NeM was based on histologic analysis along with enhanced diagnostic modalities. The patient was further treated with surgical amputation of the great toe and anti-programmed cell death-1 therapy. The patient had no relapse at 1-year follow-up. Nevoid melanoma is a rare variant of malignant melanoma on the toes, which needs to be differentiated from a nevus with atypia, with a variety of modalities including cellular and molecular profiling. The optimal treatment is amputation.

Lipomas of the Toes: An Eight-Case Series.

BACKGROUND: Lipomas, derived from adipose tissue, most frequently occur in the cephalic regions and proximal extremities, but rarely in the toes. We aimed to highlight the clinical features, diagnosis, and treatment of lipomas of the toes. METHODS: We analyzed 8 patients with lipomas of the toes who were diagnosed and treated during a 5-year period. RESULTS: Lipomas of the toes were equally distributed by sex. Patients ranged in age from 28 to 67 years (mean age, 51.75 years). Six patients (75%) had a single lesion, and all of the patients developed lipomas on the hallux. Most patients (75%) presented with a painless, subcutaneous, slow-growing mass. The duration from symptom onset to surgical excision ranged from 1 month to 20 years (mean, 52.75 months). Lipoma size varied from 0.4 to 3.9 cm in diameter (mean, 1.6 cm). Magnetic resonance imaging showed a well-encapsulated mass with hyperintense signal on T1-weighted images and hypointense signal on T2-weighted images. All of the patients were treated with surgical excision, and no recurrences were found at mean follow-up of 38.5 months. Six patients were diagnosed as having typical lipomas, one a fibrolipoma, and one a spindle cell lipoma, which needs to be differentiated from other benign and malignant lesions. CONCLUSIONS: Lipomas of the toes are rare, slow-growing, painless, subcutaneous tumors. Men and women are equally affected, usually in their 50s. Magnetic resonance imaging is the favored modality for presurgical diagnosis and planning. Complete surgical excision is the optimal treatment, with rare recurrence.

Periungual Amelanocytic Malignant Melanoma with Osteocartilaginous Differentiation of the Right Hallux: A Case Report.

Malignant melanoma with osteocartilaginous differentiation is extremely rare. We report a case of periungual osteocartilaginous melanoma (OCM) on the right hallux. A 59-year-old man presented with a rapidly growing mass with drainage on his right great toe after treatment of ingrown toenail and infection 3 months earlier. Physical examination showed a 2.0×1.5×1.0-cm, malodorous, erythematous, dusky, granuloma-like mass along the fibular border of the right hallux. Pathologic evaluation of the excisional biopsy revealed diffuse epithelioid and chondroblastoma-like melanocytes with atypia and pleomorphism in the dermis with strong SOX10 immunostaining. The lesion was diagnosed as osteocartilaginous melanoma. The patient was referred to a surgical oncologist for further treatment. Osteocartilaginous melanoma is a rare variant of malignant melanoma that needs to be differentiated from chondroblastoma and other lesions. Immunostains for SOX10, H3K36M, and SATB2 are helpful for the differential diagnosis.

Clinicopathologic Characterization of Kaposi Sarcoma on the Foot and Ankle: Analysis of 11 Patients Seen in Our Clinics.

BACKGROUND: Kaposi sarcoma (KS) has multiple clinical variants, and most frequently presents on the lower extremities. Anti-human immunodeficiency virus (HIV) therapy has significantly reduced the incidence of KS. However, KS is still prevalent in both HIV-infected and HIV-uninfected patients. This case series analysis aims to reveal the clinical presentations, differential diagnosis, and treatment options of KS on the foot and ankle. METHODS: Eleven cases of KS involving the foot and ankle were retrieved from our patient database, and their clinicopathologic features were analyzed. RESULTS: All patients were men, aged 29 to 85 years. Two types of KS were found: classic and acquired immunodeficiency syndrome-associated epidemic. The average ages of classic and epidemic KS were 65.7 and 41.8 years, respectively. Clinically, three patients manifested multiple erythematous or deep violaceous, or blue-violaceous macules on either the dorsal or plantar surfaces of both feet. Eight patients showed exophytic, pyogenic granuloma-like nodules on the plantar surface, heels, and toes. Histologically, all KSs had uniform intervening fascicles of elongated spindle cells with slit-like vascular spaces filled with red blood cells and immunoreactivity with human herpesvirus-8. The patients were treated according to HIV infection status. Human immunodeficiency virus-infected patients were treated with anti-HIV therapy after primary surgical excision or biopsy. Human immunodeficiency virus-negative patients were treated with either surgical excision, Mohs surgery, or a combination of surgical excision and local radiotherapy according to individual patient clinical presentation. CONCLUSIONS: Kaposi sarcoma is still prevalent in both HIV-infected and HIV-uninfected patients with a variety of clinical presentations. Biopsy, with histologic evaluation, in combination with immunohistochemistry is essential for the differential diagnosis. The patient should be treated according their clinical manifestation, staging, comorbidity, and immune function.

Primary Cutaneous Diffuse Large B-Cell Lymphoma, Leg Type on the Dorsal Foot in a Senior Woman: A Case Report.

Primary cutaneous diffuse large B-cell lymphoma, leg type (PCDLBCL-LT) is a rare variant of the cutaneous B-cell lymphomas, with rapid growth and poor prognosis. Here, we report a case of PCDLBCL-LT on the foot in a senior woman. An 81-year-old woman presented with a rapidly growing mass on her left foot, and discoloration in both lower legs over the past 2 months was analyzed. Physical examination revealed hyperpigmented macules and papules on both lower extremities and a 3.0 × 2.0 × 0.5-cm, gray-dark nodule on the dorsal surface of the left foot. Histologic observation of the punch biopsy specimen revealed a sheet of atypical large centroblast/immunoblast-like lymphocytes; diffusely and evenly distributed in the dermis; with the immunophenotypes of CD45-positive, CD20-positive, Melan A-negative, Sox10-negative, S-100-negative, and CK20-negative; and a very high Ki-67 proliferative index (>90%). Further punch biopsy specimens of papules in the patient's lower extremities and bone marrow did not reveal atypical lymphoid tissues. Positron emission tomography/computed tomography did not show any metastatic lesions in distant organs and lymph nodes. The lesion was diagnosed as PCDLBCL-LT stage T1N0M0. The patient was treated with four cycles of combined therapy of rituximab and cyclophosphamide, hydroxydaunorubicin, vincristine (Oncovin), and prednisolone and the tumor was further treated with local radiotherapy. The tumor size was significantly shrunken. Primary cutaneous diffuse large B-cell lymphoma, leg type is a rare entity on the foot, characterized by a confluent sheet of diffuse large centroblast- and or immunoblast-like B cells with B-cell immunophenotyping. The combined therapy of rituximab and cyclophosphamide, hydroxydaunorubicin, vincristine (Oncovin), and prednisolone is the first-line treatment regimen, with increased survival.

The Pedal Subcutaneous Phaeohyphomycotic Cyst in an Immunocompetent Adult Man: A Case Report.

Phaeohyphomycosis is a spectrum of subcutaneous and systemic infections caused by a variety of dematiaceous fungi. It is an opportunistic disease with an increased incidence in immunocompromised patients. We report a case of a pedal phaeohyphomycotic cyst in an immunocompetent adult male immigrant with the goal of highlighting its clinical presentation, diagnosis, and optimal treatment. A 57-year-old male immigrant from Panama presented with a painless, gradually increasing, large cystic lesion in his left foot, first intermetatarsal space, which had been present for many years. The patient was treated with surgical excision without antifungal therapy. Histologic analysis showed multiple granulomas composed of fibrin and necrosis in the centers surrounded by proliferative palisading fibroblasts admixed with heavily infiltrated neutrophils, plasma cells, macrophages, lymphocytes, and eosinophils. Periodic acid-Schiff and Fontana-Masson stains revealed sporadic, scattered dematiaceous fungal hyphae and pseudohyphae among granulomatous tissues. The mass was diagnosed as a phaeohyphomycotic cyst. Polymerase chain reaction-based sequencing failed to identify the fungal species because of the rarity of the fungal elements in the granulomatous tissues. The patient had no recurrence at a follow-up of 2 years. A phaeohyphomycotic cyst is a rare entity that needs to be differentiated from other benign and malignant lesions. Multiple modalities, including clinical evaluation, radiography, histologic analysis, microbiological culture, and nucleic acid sequencing, should be used for the final diagnosis. Surgical excision is an optimal treatment. Antifungal therapy should be considered based on the patient's clinical manifestation, surgical excision, and immune functional status.

Mycetoma: Development of Diagnosis and Treatment.

Mycetoma describes a heterogeneous group of cutaneous and subcutaneous infections caused by either fungi (eumycetomas) or bacteria (actinomycetomas). It is characterized by a triad of clinical symptoms: painless subcutaneous tumor-like swelling, multiple sinuses and fistulas, and discharged grains in pus. This predominantly affects the feet in more than 70% of patients. It is endemic in the "mycetoma belt" regions, including Africa, South America, and South Asia. Autochthonous mycetoma is rare in the United States of America (USA). We recently reported a Latin American immigrant with eumycetoma in the State of Maryland, USA. With millions of immigrants from endemic regions, the true number of mycetomas in the USA is most likely higher than currently recognized. With the aim to raise the awareness of clinicians about mycetoma, especially dermatologists and podiatrists, we update the development of the epidemiology, etiology, clinical presentations, pathogenesis, diagnosis, differential diagnosis, and treatment of mycetoma.

An Intradermal Spindle Cell Lipoma on the Plantar Hallux in a Patient With Scleroderma and Ehlers-Danlos Syndrome: A Case Report.

Spindle cell lipoma (SCL) is a rare variant of lipomas, which predominantly occurs in the regions of shoulder and posterior neck but rarely on the toes. Epidemiological studies have demonstrated increased incidence of cancers in patients with scleroderma. A 28-year-old female with scleroderma and Ehlers-Danlos syndrome developed a painful, skin colored, raised, polypoid lesion on the plantar side of the left hallux for several years. The lesion was surgically excised. Pathological evaluation showed intradermal bland spindle cells associated with delicate ropey/refractile collagen bundles with strong and diffuse cytoplasmic expression of CD34 but negative expression of Rb and S-100, which are consistent with SCL. We report a first case of SCL on the plantar hallux in a young female patient with scleroderma and Ehlers-Danlos disease with clinical presentations, histopathology, and treatment to raise awareness of clinicians to this rare variant of lipomas.

Fibro-Osseous Pseudotumor Arising From Nail Bed of the Great Toe: A Rare Case of Recurrence.

A fibro-osseous pseudotumor (FOPT) is a rare, rapidly enlarging, benign soft-tissue neoplasm that presents with localized pain, swelling, and redness. It typically presents in the hands and much less frequently in the feet. FOPT is characterized histologically by foci of osseous differentiation within the proliferated fibroblasts. This must be differentiated from other benign and malignant lesions. FOPT of the toes has been described in a few reports, but recurrence, following surgical excision, is extremely rare. Here we report a young, healthy female patient who presented with a rapidly growing FOPT of the left great toe. This unusual case had recurred twice following surgical excision, all within a 2-month period of time. The lesion was again completely excised, with no recurrences at follow-ups of 18 and 36 months. In conclusion, FOPT is a rare soft tissue lesion of the toes. It features fibroblastic proliferation and osseous differentiation, which needs to be differentiated from other benign and malignant tumors. The standard treatment is complete surgical excision with an excellent prognosis.

Eumycetoma, A Neglected Tropical Disease in the United States.

Eumycetoma, caused by fungi, is a neglected tropical disease. It is endemic in the "mycetoma belt" countries but rare in North America. We report a case of pedal eumycetoma in the state of Maryland. A 51-year-old male immigrant from Guatemala presented with multiple, enlarging nodules on the dorsal surface of his left great toe present for 1 year, and a new one in the left arch area present for 6 months. The nodular lesions were surgically excised in two separate operations. Pathologic evaluation of all nodules revealed eumycetomas characterized by the Splendore-Hoeppli phenomenon, showing an amorphous eosinophilic center filled with numerous fungal hyphae, observed on periodic acid-Schiff-stained slides, with a surrounding cuff of neutrophils. Polymerase chain reaction-based sequencing identified Cladosporium cladosporioides in the tissues. The patient was further treated with oral fluconazole for 2 months. The patient recovered well postoperatively and had no recurrence at 20-month follow-up. In conclusion, even though eumycetoma is regarded as a rare disease in North America, its incidence may be higher than reported because of millions of immigrants from endemic regions in the United States, which highlights the need to raise awareness of this devastating disease in the medical community. Eumycetoma needs to be differentiated from other infectious and noninfectious benign and malignant lesions. Optimal treatment includes surgical excision with antifungal therapy.

Subungual Exostosis on the Right Hallux.

Subungual exostosis (SE) is a benign, relatively uncommon bony growth underneath the nails of the distal phalanx of toes or fingers, with a majority on the toes. Clinically, it has two subvariants-protruded and nonprotruded growths from nail plates-which are treated differently. In this article, we report a case of protruded SE in a teenager with illustrative surgical excision. A 15-year-old boy presented with a painful growth on his right great toe of 6 months' duration. Physical examination revealed a 1-cm-diameter, solid, erythematous, rough, irregular growth penetrating through the skin along the dorsolateral nail bed of the right hallux with deformity of the lateral nail plate. Radiographs showed an elevated mass over the distal phalanx of the right lateral hallux. The mass was surgically excised and histopathologic examination confirmed the diagnosis of SE. The patient had no relapse or recurrence at follow-ups of 6 and 18 months. Subungual exostosis is a relatively uncommon bony growth in the toes. Radiography is favored for the diagnosis. Complete surgical excision is the optimal treatment, with rare recurrence. It needs to be differentiated from other bony lesions, including bizarre parosteal osteochondromatous proliferation, myositis ossificans, fibro-osseous pseudotumor, osteochondroma, and enchondroma.

Mycosis Fungoides Palmaris et Plantaris on the Plantar Aspect of the Foot: A Case Report.

BACKGROUND Mycosis fungoides palmaris et plantaris (MFPP) is a rare variant of the cutaneous T cell lymphoma mycosis fungoides (MF). Here we report the case of a middle-aged man with MF on the sole of his left foot. CASE REPORT A 54-year-old man had a diffuse, hard lesion in the middle of the arch on the sole of his left foot for 3 years. Physical examination revealed a 3-cm scaly, keratotic patch with slight erythema on the left plantar central arch. Histopathological evaluation of a punch biopsy specimen revealed infiltration of atypical lymphocytes in the upper dermis. Immunostaining of the atypical lymphocytes showed strong expression of CD3, CD4, and CD5; reduced expression of CD7 and CD8; and no expression of CD20. Periodic acid-Schiff staining was negative for fungi. The patient's lesion was diagnosed as MFPP and he was treated with topical psoralen plus ultraviolet A (PUVA) photochemotherapy. At 5-year follow-up, his condition was in complete remission. CONCLUSIONS MFPP is a rare clinical variant of MF restricted to the palmoplantar area, and is histologically characterized by upper dermal infiltration of atypical lymphocytes with preserved CD3, CD4, and CD5 expression but decreased CD7 and CD8 expression. PUVA photochemotherapy is a treatment option associated with excellent prognosis.

Molluscum Contagiosum on the Sole of the Foot in an Elderly Patient: A Case Report.

BACKGROUND Molluscum contagiosum (MC) presents as skin-colored, dome-shaped, umbilicated papules or nodules on the skin and is caused by the MC virus. It predominantly occurs in school-aged children and mainly affects the face, neck, and central regions of the body but, rarely, the soles of feet are affected. Here, we describe the case of a 71-year-old woman with MC on the plantar heel. CASE REPORT A 71-year-old woman presented with a 3-mm, pale, pearly, round, verrucoid lesion along the plantar central aspect of the left heel, present for 1 week. Histopathological evaluation of the excisional biopsy revealed several clusters of hyperplastic keratinocytes containing lobulated, eosinophilic, intracytoplasmic inclusion bodies inverted into the dermal layer, which was diagnosed as MC. CONCLUSIONS MC on the plantar heel is a rare, atypical presentation that needs to be differentiated from viral warts and other diseases.

Dermatofibrosarcoma Protuberans: Update on the Diagnosis and Treatment.

Dermatofibrosarcoma protuberans (DFSP) is a slow growing, low- to intermediate-grade dermal soft-tissue tumor. It has a high local recurrence rate but low metastatic potential. It is characterized by a uniform spindle cell arrangement, classically with a storiform pattern and CD34 immunoreactivity. The histomorphology and immunophenotype overlap with a broad range of other neoplasms. The standard treatment is complete surgical excision. The surgical procedures include wide local excision (WLE) with tumor free margins, Mohs micrographic surgery (MMS) and amputation. Unresectable DFSPs are treated with radiation therapy and/or targeted therapy. DFSP has characteristic t(17; 22) (q22; q13), resulting in a COL1A1- PDGFB fusion transcripts in more than 90% of DFSPs. Molecular detection of the gene rearrangement or fusion transcripts is helpful for the diagnosis of patients with atypical morphology and for screening candidates for targeted therapy with tyrosine kinase inhibitors. The aims of the present review are to update the clinical presentation, tumorigenesis and histopathology of DFSP and its variants for diagnosis and differential diagnosis from other benign and malignant tumors, to compare the advantages and drawbacks of WLE and MMS, to propose the baseline for selecting surgical procedure based on tumor's location, size, stage and relationship with surrounding soft tissue and bone structures, and to provide a biologic rationale for the systemic therapy. We further propose a modified clinical staging system of DFSP and a surveillance program for the patients after surgical excision.

PAS stain based histological classification and severity grading of toenail onychomycosis.

Onychomycosis is a common world-wide health issue. Accurate detection is essential for treatment. Multiple studies have shown that PAS-stain based histological visualization of fungal elements is superior to either direct microscopy with 20% potassium hydroxide, or fungal culture. However, PAS stain based histological classification and severity grading of onychomycosis are lacking in the literature. Here we reported a fungal detection rate of 47.87% based on an analysis of 13,805 toenails processed for H&E and PAS stains over a three year period. Based on the analysis of fungal density, distribution and infiltrating depth level in 858 PAS-positive toenails, we created a novel PAS stain based histological classification system to classify onychomycosis as occult onychomycosis (OO), focal or diffuse subungual onychomycosis (FSO or DSO), focal or diffuse plate onychomycosis (FPO or DPO), focal or diffuse subungual and plate onychomycosis (FSPO or DSPO) and superficial onychomycosis (SO). The severities of OO, FSO and FPO were graded as mild, DSO and DPO as moderate, FSPO and DSPO as severe infections, which revealed that more than 75% PAS positive toenails were severe infections. Evaluation of 97 paired toenails biopsied pre- and post-treatment from 47 patients demonstrated that the severity of infection was significantly reduced from severe to mild and moderate levels. These data indicate that the current histological classification evaluates not only the severity of the fungal infection but also the response to treatment. We further propose a guideline for treatment of onychomycosis based on the histological classification and severity.

Soft-Tissue Chondroma in the Right Hallux: A Case Report.

Soft-tissue chondroma is a rare, benign tumor. It is predominantly found in the hands and feet, but rarely in the toes. In this article, we report a digital soft-tissue chondroma that presented as a painful nodule of 5 years' duration in a 67-year-old man. Physical examination revealed a round, solid, movable nodule measuring 7 mm in diameter. Radiographs showed faint linear calcifications in the nodule under the right hallux proximal phalanx neck. The mass was completely excised, and pathologic observation revealed a mass composed of mature chondrocytes in a cartilaginous matrix, consistent with a chondroma. Even though this is a benign tumor, it needs to be differentiated from other tumors, including schwannoma, leiomyoma, chondrosarcoma, and others. Surgical excision is the preferred treatment.

Acral Lentiginous Melanoma of Foot and Ankle: A Clinicopathological Study of 7 Cases.

BACKGROUND/AIM: Acral lentiginous melanoma (ALM) is a rare entity on the foot. This study aimed to reveal its clinical presentations, histopathology and treatment options. MATERIALS AND METHODS: Seven cases of ALM involving foot were treated in our Institute in a 3-year period. RESULTS: The patients' age ranged from 38 to 84 years, with a mean of 65. The ratios of males to females and white to non-white were 4:3 and 5:2, respectively. Clinically, ALM presented as asymmetric, irregular shaped, black-brown, variegatedly discolored, papular, verrucoid, ulcerated or nodular lesions with or without pain. All ALMs were treated with either wide local excision (WLE) or toe amputation. Histologically, ALM was characterized by multiple single and nested atypical melanocytes growing along the dermal-epidermal junction, and extending into dermal layer in nodular growth pattern. CONCLUSION: ALM is a rare, asymmetric, irregularly bordered, variegatedly pigmented lesion. WLE or toe amputation is the standard treatment option.

Schwannoma of Foot and Ankle: Seven Case Reports and Literature Review.

BACKGROUND: Schwannoma is most often grown on the trunk, upper and lower extremities, and head and neck, but rarely on the foot. This study aimed to reveal clinical presentations, histopathology and treatment options for schwannoma of the foot. MATERIALS AND METHODS: Seven schwannomas out of 174 soft-tissue tumors on the foot and ankle were retrieved from our Institute in a 3-year period, and 42 schwannomas on the foot and ankle in the literature in a 30-year period were reviewed. RESULTS: The incidence of schwannoma of foot was found to be 4.0%. The patient age ranged from 8 to 84 years, with a mean of 47.4 years. More than 80% of tumors were located on the ankle, heel and plantar aspect. Overall, 77.6% of patients complained about a painful mass. Magnetic resonance imaging revealed a well-circumscribed, round or ovoid mass with iso-intensity signal compared with surrounding neuromuscular tissues on T1-weighted images and hyper-intensity signal on T2. Forty-eight out of 49 patients were treated with surgical excision or enucleation without recurrence in follow-up from 2 months to 4 years. Histologically, schwannoma was composed of hypercellular Antoni A zone with palisaded spindle cells with strong immunostaining for S-100 and hypocellular Antoni B zone with vascularization in myxoid stroma. CONCLUSION: Schwannoma of the foot and ankle is a rare, painful, indurated tumor. Magnetic resonance imaging reveals the location, size, texture and relationships with surrounding neuromuscular structures. Surgical excision is the primary treatment option with excellent outcome.

Recurrent Familial Digital Fibrokeratoma: A Case Report.

Digital fibrokeratoma (DF) is an uncommon, benign, soft tissue tumor. It usually occurs sporadically in adult males, and its recurrence is rare when treated by means of surgical removal. To the best of our knowledge, we report here the first case of recurrent female familial DF. The mother's first DF, on her right hallux, was removed when she was 32 years of age, and her second fibrokeratoma, on the left fifth toe, was removed when she was 49 years of age, and then relapsed 3 years later. The daughter's first DF, on her left fifth toe, was excised when the daughter was 24 years of age and recurred 1 year later. Both the mother's and daughter's recurrent lesions were surgically excised and pathologically diagnosed as DF. Because both the mother's and daughter's DF occurred at relatively early ages, we believe that genetic factors might play a role in the tumorigenesis of DF in this family.