The mean � standard deviation duration of warfarintreatment was 64.1 � 54.9 months, and patients withINR values of < 1.5 were regarded as candidates for sur-gery. However, a significant reduction in postoperativehemoglobin levels was observed in the warfarin group incomparison with the control group (P < 0.05).Similarly, increased postoperative bleeding rates in

patients on longterm warfarin were reported by Varkara-kis et al.3 Warfarin was stopped to reduce the INR to1.5, but patients on chronic warfarin more often requiredtransfusion (24.0% vs. 5.2%; P < 0.005) and were morelikely to demonstrate postoperative bleeding (8.0% vs.0.9%; P < 0.05) than patients who were not usingchronic anticoagulation.3

Given these data and the cessation of bleeding initiatedby a high-dose vitamin K infusion, the present patient canbe considered to have demonstrated an unexpected effectof chronic warfarin use.In summary, clinicians should remain aware that basic

parameters of coagulation are not always accurate indica-tors of the likelihood of bleeding events.

Hong Sun Jang, MD

Mi Ryung Roh, MD, PhD

Byung Ho Oh, MD

Kee Yang Chung, MD, PhD

Department of DermatologySeverance Hospital, Cutaneous Biology ResearchInstituteYonsei University College of MedicineSeoulSouth KoreaE-mail: kychung@yuhs.ac

References1 Piatkov I, Rochester C, Jones C, et al. Warfarin toxicity

and individual variability – clinical case. Toxins (Basel)2010; 2: 2584–2592.

2 Koc U, Bostanci EB, Karaman K, et al. Basic hemostaticparameters in patients with longterm oral anticoagulationundergoing cholecystectomy. J Laparoendosc Adv Surg

Tech A 2011; 21: 417–425.3 Varkarakis IM, Rais-Bahrami S, Allaf ME, et al.

Laparoscopic renal–adrenal surgery in patients onoral anticoagulant therapy. J Urol 2005; 174:1020–1023.

Palpebral sporotrichosis

Sporotrichosis is a subcutaneous mycosis caused by thedimorphic fungus, Sporothrix schenckii, which is foundworldwide, particularly in certain temperatures and tropi-cal climates. Classically, infection occurs after inoculationof the organism into the skin by abrasion with contami-nated soil, hay, thorns, decaying wood, and corn stalk.The main clinical entities include lymphocutaneous, fixedcutaneous, extracutaneous, pulmonary, and disseminated

forms. Sporotrichosis in children is rare, although fixedcutaneous sporotrichosis is more common, and the face isa frequent location for infection.1–5 However, ocular spo-rotrichosis in children is very rarely reported.6–8 Herein,we report a new case in a child.A 3-year-old boy presented with a 3-month history of

an enlarging, nontender, erythematous plaque on the leftlower eyelid. The lesion started as a painless papule andprogressed to plaque. Physical examination revealed an

(a) (b) (c)

Figure 2 (a) On postoperative day 1, the patient returned to the hospital with uncontrolled bleeding and swelling. (b) Onpostoperative day 2, stitches were removed and electrocoagulation was attempted; however, blood continued to ooze from allover the wound bed. (c) During the 12-month follow-up, the patient showed no signs of further bleeding and the flap healedwith an acceptable cosmetic outcome

International Journal of Dermatology 2014, 53, e347–e366 ª 2014 The International Society of Dermatology

Correspondencee356

erythematous plaque with slight scales, which were pres-ent on the left lower eyelid (Fig. 1). No adenopathy waspresent. There was no history of trauma, fever, weight

loss, and ophthalmologic symptoms. Before the diagnosis,the patient had been treated with topical antibiotics, butthe condition did not improve. Hordeolum and otherinfections were considered in the differential diagnosis. Abiopsy was taken and used for culture and histologicexamination. Hematoxylin and eosin-stained sectionsshowed granuloma tissue with infiltration of lymphocytesand plasma cells (Fig. 2a). Periodic acid-Schiff stainingshowed typical blastospore (Fig. 2b, arrow). Tissue cul-ture grew Sporothrix schenckii. Laboratory studiesrevealed a normal complete blood cell count.Taking the clinical, culture, and histologic findings into

account, the erythematous plaque was diagnosed as afixed cutaneous sporotrichosis. He was treated with 10%solution of potassium iodide (0.25–1 g/day) in combina-tion with itraconazole (oral, 50 mg BID) for three months.The lesion started improving after one month and healedwith a scar over a period of three months.

Yaqin Zhang, MD, PhD

Venkatesh Pyla, MBBS

Department of Dermatology and VenereologyThe Second Hospital of Jilin UniversityChangchunChinaE-mail: yaqingang@aol.com

Funding sources: Supported by Jilin Provincial Science& Technology Department (No.20110738).Conflicts of interest: None.

References1 Song Y, Yao L, Zhong SX, et al. Infant sporotrichosis in

northeast China: a report of 15 cases. Int J Dermatol

2011; 50: 522–529.2 Pappas PG, Tellez I, Deep AE, et al. Sporotrichosis in

Peru: description of an area of hyperendemicity. ClinInfect Dis 2000; 30: 65–70.

3 Rafal ES, Rasmussen JE. An unusual presentation of fixedcutaneous sporotrichosis: a case report and review of theliterature. J Am Acad Dermatol 1991; 25: 928–932.

4 Itoh M, Okamoto S, Kariya H. Survey of 200 cases ofsporotrichosis. Dermatologica 1986; 172: 209–213.

5 Kariya H, Iwatsu T. Statistical survey of 100 cases ofsporotrichosis. J Dermatol 1979; 6: 211–217.

6 Parekh PK, Butler DF. What is your diagnosis? Periorbitalgranulomatous plaque Pediatr Dermatol 2011; 28: 457–458.

7 Witherspoon CD, Kuhn F, Owens SD, et al.Endophthalmitis due to Sporothrix schenckii afterpenetrating ocular injury. Ann Ophthalmol 1990; 22:385–388.

8 Jin XZ, Zhang HD, Hiruma M, et al. Mother-and-childcases of sporotrichosis infection. Mycoses 1990; 33:33–36.

Figure 1 Erythematous plaque with slight scales on the leftlower eyelid

(a)

(b)

Figure 2 (a) Infiltration of inflammatory cells, comprisinglymphocytes and plasma cells (hematoxylin and eosin stain,original magnification, 910). (b) Blastospore (arrow)(periodic acid–Schiff stain, original magnification 9400)

Correspondence e357

ª 2014 The International Society of Dermatology International Journal of Dermatology 2014, 53, e347–e366