Surgical resection of a rare cutaneous manifestation of Scedosporium apiospermum in a patient who underwent renal transplant

Abstract

A man aged 47 years who was immunosuppressed following renal transplantation for focal segmental glomerulosclerosis was referred to the Plastic Surgery team for management of a painful, chronic, granulomatous lesion of the right forearm. Serial ultrasound scans and MRI scans were not diagnostic, but microbiological specimens tested positive for the fungus Scedosporium apiospermum The renal transplant graft-which was failing-was removed, allowing him to cease immunosuppression. He then underwent a resection of the lesion and reconstruction with a split thickness skin graft. Analysis of the specimen revealed fibrosis, granulomatosis and a collection of S. apiospermum He was started on voriconazole which, in conjunction with his surgical resection, appears to have kept the disease at bay. With increasing numbers of solid organ transplants and improved survival, this case highlights the growing burden of rare, opportunistic infections, the difficulty in diagnosis and the need for specialist intervention.

Figure 1

MRI section showing multilobular, solid, granulomatous tissue extending from volar skin into the deep flexor muscle compartment, reaching down to the median nerve, the interosseous and radial arteries. Ul, ulna; R, radius; BV, basilic vein; CV, cephalic vein; PIN, posterior interosseous nerve; UA, ulnar artery; RA, radial artery; RN, radial nerve.

Figure 2

Contrast-enhanced CT was requested to delineate the anatomy (especially in relation to the radial artery) and to plan for surgery. This section demonstrates a 10×6×3 cm collection, the majority of which lies within the superficial subcutaneous fat, but extending down between the radial artery and the more volar of the interosseous arteries. Patent arterial flow is demonstrated with no extravasation. R, radius; Ul, ulna; RA, radial artery; IA, interosseus artery.