Deep dermatophytosis caused by Trichophyton rubrum with concomitant disseminated nocardiosis in a renal transplant recipient page 1
Deep dermatophytosis caused by Trichophyton rubrum with concomitant disseminated nocardiosis in a renal transplant recipient page 2
Deep dermatophytosis caused by Trichophyton rubrum with concomitant disseminated nocardiosis in a renal transplant recipient page 3
Deep dermatophytosis caused by Trichophyton rubrum with concomitant disseminated nocardiosis in a renal transplant recipient page 4

Deep dermatophytosis caused by Trichophyton rubrum with concomitant disseminated nocardiosis in a renal transplant recipient

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    tacrolimus.The pagination of this article was incorrect as originally publishedDermatologic examination revealed a 2.5-cm di-ameter, well-demarcated, solitary, firm, nontender,dusky-red to purple tumor on the medial aspect ofthe patients left thigh (Fig 1). Interdigital toe-webmaceration, onychodystrophy, and discoloration ofthe fingernails (first, second, and fourth fingers of theright hand) and both big toenails were also noted.Complete blood count, erythrocyte sedimentationrate, urinalysis, and serum levels of C-reactive pro-tein, fasting glucose, liver enzymes, blood ureanitrogen, and creatinine were within normal limits.Serology was negative for antihuman immunodefi-ciency virus antibodies, and positive for antihepatitisC virus and antihepatitis B surface antigen antibodies.

    (2004:51;S101-S104). Please use the corrected page numbers

    listed online at, in the corrected table of

    contents, or in the December 2004 index in future citations.

    This supplement is made possible through the

    generous support of Stiefel Laboratories for the

    American Academy of Dermatology.

    Departments of Dermatologya and General Surgery,b BasxkentUniversity Faculty of Medicine; and Department of Microbiol-

    ogy, Hacettepe University Faculty of Medicine.c

    Funding sources: None.

    Conflicts of interest: None identified.

    Presented at the American Academy of Dermatology 60th Annual

    Meeting, New Orleans, Louisiana, February 22-27, 2002.

    Reprint requests: Deniz Seckin, MD, Basxkent University Facultyof Medicine, Department of Dermatology, 5. Sokak, No. 48,

    Bahcelievler, 06490, Ankara, Turkey. E-mail: denizs@baskent-ank. dermatophytosisrubrum with concomitan

    in a renal tran

    Deniz Seckin, MD,a Sevtap Arkan, MAnkara

    Deep dermatophytosis and nocardiosis are uncommimmunosuppressed with deep dermatophytosisdisseminated nocardiosis. The infections occurtransplantation, and may have been related to tacrol

    Organ transplant recipients receive long-termimmunosuppressive therapy to help pre-vent graft rejection and are, therefore,

    at increased risk for opportunistic infection.1,2

    Dermatophytes are keratinophilic organisms, andmost dermatophytic infections are confined to thestratum corneum, hair, and nails. These organismsare not generally regarded as opportunisticpathogens; however, they do occasionally invadethe dermis, subcutaneous tissue, and internal visceralorgans and cause atypical aggressive infections,particularly in individuals who are immunocompro-mised.3-5 The current literature documents fewerthan 100 cases of deep dermatophytosis.

    Nocardia species are ubiquitous environmentalsaprophytes that live in soil, organic matter, andwater.6 Nocardiosis is usually an opportunistic in-fection, and is an uncommon but important causeof morbidity and mortality in organ transplant re-0190-9622/$30.00

    2004 by the American Academy of Dermatology, Inc.doi:10.1016/j.jaad.2004.05.008used by Trichophytonisseminated nocardiosislant recipient

    c and Mehmet Haberal, MD, FACSb


    infections. This article describes a patient who wassed by Trichophyton rubrum and concurrent16 years after the patient underwent renals therapy. ( J Am Acad Dermatol 2004;51:S173-6.)

    cipients.7,8 Most such infections arise from directinoculation of skin or soft tissues, or by inhalation.6-8

    We describe a renal transplant recipient who haddeep dermatophytosis caused by Trichophytonrubrum and concurrent disseminated nocardiosis.To our knowledge, no such association in a patientwith renal transplant has been reported in theliterature to date.

    CASE REPORTIn December 2000, a 45-year-old man was re-

    ferred for evaluation of a mass on his left thigh thathad been present for 2 weeks. The patient hadundergone kidney transplantation 16 years earlier.He had no history of penetrating trauma or insectbite at the affected site. His immunosuppressivetreatment had consisted of prednisolone, azathio-prine, and cyclosporine until October 2000, when hehad experienced an episode of allograft rejection.This was treated with pulse-corticosteroid therapy,and the cyclosporine in his regimen was switched toPotassium hydroxide preparations of scrapings ofthe toe webs and dystrophic nails showed septatehyphae. Samples fromanexcisional biopsy specimen



    S174 Seckin, Arkan, and Haberalof the tumoral lesion were sent for histopathologicstudy, and bacterial and fungal cultures. The histo-pathologic examination revealed pseudoepithelio-matous hyperplasia of the epidermis, and denseinflammatory infiltrate, focal microabscess forma-tion, and extensive hemorrhage throughout thereticular dermis. The infiltration was not associatedwith hair follicles. Themicroabscesses featured poly-morphonuclear leukocytes and nuclear debris attheir center, and histiocytes and multinuclear giantcells at the periphery. Some of the giant cells hadengulfed clear globular material, which periodicacid-Schiff staining confirmed was a fungal structure.Multiple swollen, thick-walled, periodic acid-Schiffpositive, septate hyphae were also observedin the extracellular component of the dermis (Fig 2).Deep fungal infection, including dermatophytosis,was suggested.

    The patient was started on oral terbinafine (250mg/d); however, 2 weeks later he was readmittedbecause of pain and diminished vision in his left eye.Fundoscopic examination revealed a plaque lesionsuggestive of fungal endophthalmitis. Terbinafinewas discontinued, and empirical treatment with in-travenous liposomal amphotericin B (3 mg/kg/d)and an intravitreal injection of amphotericin B wereadministered for probable invasive fungal infectionof the eye. The patient became febrile on the thirdday in hospital. A chest radiograph showed diffusepatchy infiltration of both lungs. Thoracic computedtomography demonstrated a 3-cm diameter solidmass in the basal segment of the left lung. Neurologicexamination revealed weakness of the left lowerlimb and diminished consciousness. Magnetic reso-nance imaging showed multiple brain abscesses (Fig3). The patients clinical condition worsened; hedeveloped generalized seizures and was placed onantiepileptic therapy.

    A vitreous sample was obtained by fine-needle

    Fig 1. Firm, nontender, dusky-red to purple tumor causedby Trichophyton rubrum.aspiration, and modified acid-fast staining of thismaterial showed delicate, long, thin, branching, andweakly acid-fast filaments characteristic of Nocardiaspecies (Fig 4). A sample of vitreous and a bloodculture both grewNasteroides. The patient was giventhe diagnosis of disseminated nocardiosis featuringmultiorgan involvement, namely, ophthalmic, pul-monary, and central nervous system lesions.Tacrolimus, azathioprine, and amphotericin B werediscontinued. The immunosuppressive therapy wascontinued with prednisolone and combination anti-microbial therapy with trimethoprim-sulfametho-xazole, amikacin, and cefotaxime was initiated. Thepatients clinical status improved dramatically in thefirst week, and 2 weeks later he was discharged fromhospital.

    One month after initial presentation, fungalcultures of the skin tumor and the nail and toe-webscrapings grew T rubrum (Fig 5). This confirmed thediagnoses of deep dermatophytosis for the skintumor, and tinea unguium and tinea pedis.

    After discharge, the patient continued to receivelong-term treatment for nocardiosis with trimetho-prim-sulfamethoxazole, amikacin, and imipenem.Amikacin was stopped after 3 months, as a resultof ototoxicity. Trimethoprim-sulfamethoxazole wasdiscontinued in the fifth month because of elevatedliver enzymes, and imipenem was switched to mer-openem at this stage as well. After 7 months oftherapy, the lesions in the lungs and central nervoussystem were almost completely resolved. Thenocardiosis therapy was stopped after 12 months.In July 2002, cyclosporine and mycophenolatemofetil were added to the immunosuppressive treat-ment with prednisolone. Three years after his firstadmission, the patient remains free of disease but istotally blind in his left eye.

    DISCUSSIONDermatophyte infections can present in various

    Fig 2. Thick-walled, short, swollen septate hyphae andsporelike organisms in reticular dermis. (Periodic acid-Schiff stain; original magnification: 340.)atypical ways. These presentations include differenttypes of subcutaneous and deep dermal lesions


    Seckin, Arkan, and Haberal S175(papules,5,9,10 nodules,3,5,10 plaques,3,5 cellulitis,11

    abscesses,4,12 draining sinuses,13 verrucous le-sions,14 blastomycosis-like lesions15) and, rarely,lymphogenous or hematogenous extension.16 Suchatypical features are mostly encountered in individ-uals who are immunocompromised.3-5 T rubrum isthe causal agent in most cases of deep derma-tophytosis.3 Patients with deep dermatophytosisusually have concurrent chronic superficial derma-tophyte infection, such as tinea unguium, whichsuggests autoinoculation in the pathogenesis.3,4,15

    Clinical, pathologic, and microbiologic diagnosisof deep dermatophytosis in individuals who areimmunocompromised can be difficult.3,4,9,15,17,18

    Our patient initially presented with a red-purpletumoral lesion, so we initially suspected a neoplasticcondition (cutaneous lymphoma or Kaposis sar-coma) or a deep fungal infection like cutaneousaspergillosis. When histopathologic examinationrevealed multiple septate hyphae in the dermis,our focus was a deep fungal infection, such asdermatophytosis. However, as has been notedpreviously in the literature on deep dermatophyto-sis,9-12,15 instead of the typical slender hyphae foundin the stratum corneum in superficial dermatophyto-sis, the hyphae in our patients de