British Society for Skin Care in Immunosuppressed Individuals

BI01 Deep Trichophyton rubrum infection of the posterior thoracic wall in a transplant patient: a peculiar case of fungal dimorphism A. Yaakub, T.S. Chohan, D. Ondhia and S.N. Shah Norfolk and Norwich University Hospital, Norwich, U.K.; Birmingham Skin Centre, Birmingham, U.K. and Leeds Teaching Hospitals NHS Trust, Leeds, U.K. A 45-year-old woman presented with a 2-month history of two intensely itchy nodules at the left midback. There was a background of IgA nephropathy with a renal allograft, type 2 diabetes mellitus and abdominal tuberculous lymphadenitis. Her medications included oral mycophenolate mofetil, prednisolone, moxifloxacin, pyridoxine, isoniazid and gliclazide. On examination, the nodules were red, shiny and umbilicated. The initial diagnosis was molluscum contagiosum. Excision showed granulomatous inflammation in the dermis with large encapsulated budding spores and hyphae in keeping with a dimorphic fungal infection. The tissue was not processed for fungal culture, thus a further curettage and cautery was arranged and topical terbinafine cream twice daily was commenced. After multiple failed attendances, she re-presented with a large indurated plaque at the same location with clusters of superficial papules and nodules. Trichophyton rubrum was isolated on tissue culture and thoracic magnetic resonance imaging showed a paraspinal, 3.6-cm, lobulated lesion within the subcutaneous fat. There was complete clinical resolution after 6 months of terbinafine 250 mg on alternate days. Trichophyton rubrum is the most common cause of superficial dermatophytosis worldwide, but deep dermal and subcutaneous infection (i.e. Majocchi granuloma) is rare. Both immunocompetent and immunocompromised patients can present with a follicular pattern of localized shiny papules, resembling molluscum contagiosum. However, more invasive disease occurs exclusively in the immunocompromised and is characterized by deep-seated, subcutaneous plaques. Dimorphism is a peculiar characteristic of several fungi, namely the ability to switch between a cellular yeast and a filamentous form. Trichophyton rubrum dimorphism has been demonstrated in vitro, but there is only one other in vivo case report (Lillis J, Dawson E, Chang R, White C. Disseminated dermal Trichophyton rubrum infection – an expression of dermatophyte dimorphism? J Cutan Pathol 2009; 37: 1168–9). The reduced host immune response may provide an environment for the fungus to express its inherent dimorphism. We present a rare case of Majocchi granuloma with dimorphism of T. rubrum. BI02 Thinking outside the box: a challenging case of mucormycosis presenting as a necrotic cutaneous nasal plaque A. Wernham, G. Fremlin and J. Yoo University Hospitals Birmingham NHS Trust, Birmingham, U.K. Immunosuppressed patients are predisposed to atypical fungal infections, sometimes with severe consequences. We report an acute presentation of an atypical fungal infection in a severely immunocompromised patient with a complicated medical background, which initially puzzled clinicians. A 36-year-old Iraqi man, living in the U.K. for 14 years, was admitted with neutropenic sepsis under haematology with a background of recurrent high-grade synovial pharyngeal sarcoma and newly diagnosed acute myeloid leukaemia, treated with FLAG (fludarabine, cytarabine and G-CSF). He was referred to dermatology with a 1-week history of an enlarging, painful, necrotic plaque on the right of his nose. He described associated nasal congestion and his observations demonstrated a recurring low-grade pyrexia. On examination, there was a well-circumscribed necrotic plaque measuring 4 9 3 cm involving the right nasal sidewall, ala, tip and soft-tissue triangle. He had no lesions elsewhere and no palpable lymphadenopathy. At the time of review, his white cell count was zero. A differential diagnosis of vasculitis or atypical infection was considered, including mucormycosis, atypical mycobacteria, leishmaniasis and syphilis. Four punch biopsies were taken from the inflamed edge. Initial haematoxylin and eosin sections demonstrated hyperparakeratosis with distended and plugged follicles, mostly in keeping with rosacea. However, fungal culture demonstrated the presence of Rhizopus microsporus, confirming a diagnosis of mucormycosis. While it was sensitive to isavuconazole, this drug was not available in liquid form and he was unable to swallow due to his pharyngeal disease. His dose of amphotericin B was therefore increased to 7 mg kg 1 and posaconazole was added as a holding measure. A flexible nasendoscopy did not demonstrate involvement of the sinuses. He was referred to plastic surgery with a view to excision of the necrotic tissue. This resulted in a significant nasal deformity, requiring a delayed and challenging nasal reconstruction. Mucormycosis is a serious, rare fungal infection, mainly affecting individuals who are immunosuppressed. The condition refers to several genera of fungi in the order of Mucorales, with Rhizopus being the most common. These typically affect the facial sinuses, but can also involve other organs including the lungs, brain, skin and gastrointestinal systems. In some cases the disease becomes disseminated leading to a