A deep fungal infection mimicking a skin tumour in a kidney recipient patient

Krisztina Bottyán, Réka Németh, Erika Varga, Irma Korom, Lajos Kemény, Judit Oláh         

Department of Dermatology and Allergology, University of Szeged, Hungary

Case presentation: A 56-year-old female presented with an approximately two-month history of a rapidly growing erythematous nodule on her right leg. The patient complained of a serious fluid oozing from the lesion. She denied any injury or trauma. The dermoscopic findings were asymptomatic and suggested a possible diagnosis of a non-melanoma skin tumour or adnexal tumour.

Figure 1. A–B. A 13x18 mm, dome-shaped erythematous nodule was located above the right ankle with a small central ulceration.

Figure 2. Dermoscopic features of the lesion 

The patient’s medical history included hypertonia, insulin-dependent diabetes mellitus, hyperlipidaemia and endometriosis. End-stage renal disease (ESDR) developed as a consequence of chronic glomerulonephritis. In 2011, she had undergone a live-donor kidney transplantation, but two months later a graftectomy had to be performed due to graft rejection. In 2014, she had had a successful allotransplantation of a cadaver kidney. Conventional immunosuppressive combined therapy has consisted of tacrolimus, mycophenolic acid and corticosteroids over the last three years.

Diagnostic work-up and treatment: Clinical findings, the history of rapid growth and the immunosuppressive condition strengthened the diagnosis of a tumoral origin, so an excision was performed. A microscopic examination revealed an abscess-forming granulomatous inflammation at the border between the dermis and subcutis. PAS staining identified a large number of fungal elements within and outside the macrophages around the abscess. The histological findings confirmed the diagnosis of a cutaneous deep fungal infection.

Figure 3. Histological findings. A. H/E staining showed an abscess-forming granulomatous inflammation at the border between the dermis and subcutis. B. PAS staining identified a large number of fungal elements within and outside the macrophages around the abscess.

Key message: Solid organ transplant recipients have an increased risk of developing cancer.  Infection is the second leading cause of death in kidney-transplanted patients. In patients receiving immunosuppressive therapy, a simple fungal infection can present in unusual clinical forms. Given its atypical, sometimes aggressive presence, recognizing one is a great challenge, and it can easily lead to a misdiagnosis.

Fungal infection and non-melanoma skin tumours often have a similar, non-specific clinical appearance. This case emphasizes the importance of both microbiological analysis and biopsy.

References

  1. Jensen P., Møller B., Hanse S. Skin cancer in kidney and heart transplant recipients and different long-term immunosuppressive therapy regimens. J Am Acad Dermatol. 2000; 42(2 Pt. 1): 307.
  2. Seckin D, Arikan S, Haberal M. Deep dermatophytosis caused by Trichophyton rubrum with concomitant disseminated nocardiosis in a renal transplant recipient. J Am Acad Dermatol 2004; 51: S173–S176.
  3. Thotan SP1, Kumar V, Gupta A, Mallya A, Rao S. Subcutaneous phycomycosis--fungal infection mimicking a soft tissue tumor: a case report and review of literature. J Trop Pediatr. 2010 Feb; 56(1): 65-6. doi: 10.1093
  4. Farrugia  D, Mahboob  S, Cheshire  J,  et al.  Malignancy-related mortality following kidney transplantation is common.  Kidney Int. 2014; 85(6): 1395–1403.

 

 

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