ARTICLE
Auteur(s) : Anshu Awasthi1,
Ritambhra Nada1, Somesh Gupta2, Vinay
Sakhuja3, Kusum Joshi1
1Department of Histopathology, Postgraduate Institute
of Medical Education & Research Chandigarh, India, 160012
2Department of Dermatology, Venerology, and Leprology;
Postgraduate Institute of Medical Education & Research
Chandigarh, India, 160012
3Department of Nephrology; Postgraduate Institute of
Medical Education & Research Chandigarh, India, 160012
accepté le 11 Octobre 2004
Cell mediated immunity, especially by epidermal Langerhans cells,
is the main defense mechanism against dermatophytes, and its
inhibition by immunosuppressive drugs predisposes solid-organ
transplant recipients to dermatophytoses [1]. These cutaneous
fungal infections may present in a variety of nonspecific or
atypical ways in immunocompromised patients and require a high
index of suspicion to diagnose correctly [2].
Case report
A 38 year old male renal allograft recipient who was on oral triple
drug immunosuppression (prednisolone, cyclosporine and
azathioprine) for 2 years presented to the Dermatology clinic with
the insidious development of multiple scalp nodules. These nodules
were painless, non-tender, 1-2 cm in size and distributed all over
the scalp ( (figure
1) ). There was no previous history of the use of topical
steroids. The clinical diagnosis was that of an appendigeal tumour
and a biopsy was performed from one of the nodules.
Histopathological examination unexpectedly revealed an organizing
abscess comprising of polymorphonuclear leukocytes, macrophages and
giant cells surrounding disrupted hair follicles ( (figure 2) ). The endothrix
of these hair follicles revealed multiple round as well as box-like
arthrospores consistent with the morphology of tinea capitis (
(figure 3) ).
These spores were PAS positive and were also found within the giant
cells present in the abscess. The overlying epithelium showed
irregular acanthosis and acute perifolliculitis. There was no
evidence of any dysplastic changes or malignancy in either the
epidermis or the dermal appendages. Cultures were not sent since an
infective lesion was not considered while performing the biopsy.
There was a dramatic clinical response to itraconazole 200 mg daily
in two divided doses given for one month.
Discussion
Renal transplant recipients on immunosuppression are at increased
risk of opportunistic cutaneous fungal infections [3]. Cutaneous
manifestations of candidiasis, pityrosporum folliculitis and
chromomycosis (dematiaceous fungi) are usually observed early after
transplantion, cryptococcosis more than 6 months later, while the
frequency of dermatophytoses increases as time goes by [4, 5]. The
risk of infection depends on the degree of immunosuppression and
the presence of pathogenic fungi in the environment [3, 6]. Cell
mediated immunity, especially through epidermal Langerhans’ cells,
plays an important part in the elimination of dermatophytes and
these cells are reduced in density in patients on azathioprine,
thus compromising cutaneous defenses [1, 7]. The inhibition of
immunologically competent T lymphocytes also predisposes these
patients to malignancies, of which the most common are skin
cancers. These tumors appear frequently at multiple sites, present
at an earlier age and behave more aggressively than in the general
population and are commonly considered as differential diagnoses in
transplant recipients with skin lesions [8].
It is usually not difficult to clinically differentiate
cutaneous fungal infections from skin cancers and approximately 90
percent of benign or malignant cutaneous lesions are characterized
accurately by clinicians [1]. However this dictum may not always
hold true because cutaneous fungal infections in solid-organ
transplant patients may present in a variety of nonspecific or
atypical ways, requiring a high index of suspicion to diagnose
correctly [2]. The atypical features of dermatophytoses described
in this group of patients include disseminated involvement,
relative lack of inflammation and pruritus as well as a higher risk
of treatment failure [9, 10]. In addition a destructive form of
dermatophytosis characterized by follicular invasion also known as
Majocchi’s granuloma trichopyticum has been reported in
immunocompromised patients [11]. However, to the best of our
knowledge, this is the first report of dermatophytosis presenting
with such an exuberant inflammatory reaction and nodule formation
that it was clinically mistaken to be an appendigeal tumour.
It is often believed that fungal hyphae or spores are usually
not seen in cases in which the inflammatory reaction is prominent
[12]. However, in our case the co-existence of several arthrospores
and a florid inflammatory response has been elegantly demonstrated.
Although prominent inflammation was seen morphologically these
cells may have been functionally incompetent as evidenced by the
increased fungal load and absence of other clinical signs of
inflammation like pruritus or erythema. The clinico-pathological
characteristics were probably altered by iatrogenic
immunosuppression.
With regard to the aetiologic microorganism, sending the biopsy
specimen for culture may have confirmed the identity of the
aetiologic agent. This, however, was not possible since a fungal
infection was not clinically suspected while performing the biopsy.
The characteristic morphology, PAS positivity and dramatic response
to itraconazole indicate that the aetiology was of fungal
origin.
The use of immunosuppression enhances the risk of failure of
antifungal therapy and prolonged treatment as well as close
follow-up is essential to ensure complete cure of dermatophytoses
in renal transplant recipients. This is exemplified by
Virgili’s description of a case of tinea capitis
relapsing thrice over a period of two and a half years in spite of
adequate treatment [13]. The lesions in our case however have
completely disappeared after the administration of itraconazole.
The index case is under regular follow up and there have been no
recurrences for the past one and a half years in spite of continued
immunosuppression.
To conclude, our case illustrates that cutaneous fungal
infection in immunocompromised patients can have atypical
presentations even mimicking malignancy and a high index of
suspicion is required to accurately diagnose this eminently
treatable condition.
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