infarction and can simulate a bruise Infection is often at the site of trauma (including IV or surgical site) Localized infection with opportunistic fungi can also present as a pustular eruption if the fungus is present under occlusion such as tape or an arm board It is vital to identify localized opportunistic fungal infections immediately to prevent dissemination A biopsy with histopathologic evaluation and tissue culture can establish the diagnosis and fungal sensitivities Since the cause of an erythematous or necrotic skin lesion in an immunosuppressed patient can be bacterial, viral, or fungal, a tissue Gram stain or frozen section from tissue biopsy can help make a rapid diagnosis Patients with suspected opportunistic fungal infections should be treated with antifungals under the guidance of an infectious disease specialist Deep Fungal Infections Deep fungal infections are typically acquired as pulmonary infection through inhalation of the spores when the soil is disrupted and the spores are aerosolized Cryptococcosis, histoplasmosis, blastomycosis, coccidioidomycosis, and paracoccidioidomycosis are common causes of deep fungal pulmonary infection in normal hosts in North America This pulmonary infection can disseminate, or some of the spores can cause primary infection around the mouth Primary infection is uncommon but presents with inflamed papules or nodules, often with crusting or erosion typically perioral, perinasal, or involving the oral mucosa There also can be secondary reactive skin changes such as erythema nodosum (EN) EN is characterized by red, painful subcutaneous nodules, most specifically on the anterior shins The nodules seem to be reactive and not truly infectious and there are many other causes of EN Deep fungal infections can also manifest as nodules or verrucous plaques when directly inoculated into the skin Sporotrichosis often presents this way after direct inoculation of the fungus into the skin The fungus Sporothrix schenckii lives on various plants and vegetation, including rose thorns, sphagnum moss, and carnations Once inoculated into the skin, the fungus spreads along the lymphatic drainage (sporotrichoid pattern) up the affected arm or leg Diagnosis of cutaneous deep fungal infections is best proven with biopsy for histopathology and fungal culture The specimen should also be sent for