Figure. . A) Edema and erythema of the flexor surface of the hand of patient with paracoccidioidomycosis, carpal tunnel syndrome, and flexor tenosynovitis, Brazil. Note a fistulous pustulous nodule in the right thumb and forearm (arrows) and flexor contracture of the fourth finger. B) Flexor surface of the hand and forearm after surgery. C) Paracoccidioides brasiliensis was directly identified on the thumb secretion, sputum, and flexor tenosynovectomy specimen by using a 10% potassium hydroxide preparation. This image was obtained from the thumb secretion. Note the characteristic multiple-budding yeast cells (pilot's wheel) with the well-defined refringent double wall.