Abstract:

A 69-year old male landscaper with a history of well-controlled mycosis fungoides presented with a new erythematous eruption on the right arm. The patient denied pruritus or pain but stated the plaques would occasionally fissure. Physical exam revealed pebbly violaceous and erythematous papules coalescing into plaques with overlying scale on his right arm, worse on the right antecubital fossa. A 3mm punch biopsy was done, which showed a polymorphous perifollicular infiltrate; PAS and GMS stains highlighted possible fungal organisms in the dermis. As the biopsy results were most consistent with deep fungal infection, another specimen was sent for atypical mycobacterial and fungal cultures. Tissue culture showed no growth at 4 weeks, and a chest x-ray returned unremarkable. Despite negative cultures, the patient completed a 14-day course of oral fluconazole. He was then started on oral terbinafine, but when a repeat punch biopsy showed only pseudoepitheliomatous hyperplasia and scar, terbinafine was stopped. At a follow-up visit for his mycosis fungoides several months later the rash had recurred. Another 3mm punch biopsy was done, showing septate hyphae and spores within granulomatous inflammation, and thus another tissue culture was sent. He was restarted on oral fluconazole. Tissue culture grew Alternaria species. Cutaneous alternariosis is caused by infection with the Alternaria species of dematiaceous fungi. Predisposing factors for infection include frequent contact with soil, as in this patient, a landscaper. This case highlights the importance of subsequent biopsies and tissue cultures when there is clinical or histopathologic suspicion for deep fungal infection.

Financial Disclosure:
No current or relevant financial relationships exist.

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Audrey Fotouhi, MD