Abstract:

This is a case of a 90-year-old man with a history of prostate cancer and coronary artery disease presenting to the clinic for five months of a painful rash in the right groin. He was previously treated with multiple antibiotics and antivirals without improvement, and was otherwise asymptomatic. On examination, scattered erythematous papules with white, hard, protruding domes were present on the right thigh. Differential diagnoses included herpes zoster vs deep fungal infection vs a neutrophilic dermatosis. Histopathological evaluation revealed budding yeast, pseudohyphae, and septate hyphae consistent with Candida and both tissue and fungal culture grew pan-sensitive Candida albicans. PCR for herpes viruses was negative. The patient was started on topical clotrimazole and triamcinolone. On follow-up, the patient’s lesions were improving and his caretakers had debulked the majority of the hard domes and brought them for further analysis. A separate biopsy from adjacent skin had been interpreted by an outside laboratory as demonstrating gout. Evaluation of the material from the protruding dome under polarized light revealed a mix of yellow, blue, and orange parallel crystals consistent with monosodium urate deposition. Combining the clinical setting of multiple white hard domes without any history of gout or elevated uric acid levels and the histopathological finding of embedded Candida within this chalky material, the final clinical diagnosis was an isolated region of perforating gout with superimposed Candida infection. With the majority of the crystals removed, continued application of topical therapy, and initiation of allopurinol; the patient’s lesions were greatly improved at the final follow-up. This case documents growth of Candida in transepidermally eliminated gout and should serve as a reminder for dermatologists and dermatopathologists to take into consideration the possibility of transepidermal elimination of urate crystals in unusual circumstances.

Financial Disclosure:
No current or relevant financial relationships exist.

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Neal Shah, MD