COEXISTENCE OF CUTANEOUS AND PRESUMPTIVE PULMONARY ALTERNARIOSIS

A 71-year-old man presented with an asymptomatic lesion on the arm. He was born in rural West Virginia, spent several years in military serv ice in the South Pacific, and is a long-term resident of Maine. He has chronic obstructive pulmonary disease, coronary artery disease, and n oninsulin-dependent diabetes melitus. He was evaluated for episodes of hemoptysis by bronchoscopy in 1980 and 1984, but no cause was establi shed. His usual medications included prednisone 10 mg daily. One month prior to the dermatology consultation the patient had been admitted t o another hospital because of a flare-up of his lung disease. He was t reated for 10 days with intravenous steroids and bronchodilators, resu lting in improvement of his respiratory status. A cardiac pacemaker wa s inserted because of arrythmias. By the time of discharge, 1 week lat er, the prednisone dose had been tapered to his usual 10 mg daily. One week prior to the dermatology consultation, he was admitted to this i nstitution for evaluation of recurrent atrial fibrillation. On admissi on, his chest X-ray revealed a pulmonary nodule which had not been pre sent 1 month previously (Fig. 1a). The dermatology service was asked t o evaluate an enlarging lesion on the right arm. The arm lesion began 2 weeks earlier as a group of papules which grew and coalesced. Two da ys prior to evaluation, the lesion had spontaneously drained purulent material. There was no pruritus or pain. The patient did not recall an y similar skin problem in the past and had no history of trauma to the area. He reported a 30 lb weight loss in the 2 months prior to admiss ion despite a good appetite. There was no history of fever or malaise. On examination, a 3.3 x 1.5 cm plaque was noted on the right extensor forearm just above the wrist (Fig. 2). The plaque was erythematous wi th a shiny atrophic epidermis and fine scale. One portion of the plaqu e had a red-yellow hue and was indurated while the other had a grey-bl ue pigmented appearance. The remainder of his skin examination was unr emarkable. There was no adenopathy or hepatosplenomegaly. Routine labo ratory tests were significant for hyperglycemia, a mildly elevated whi te blood cell count of 11.5 K/UL with a normal differential; lactate d ehydrogenase was 325 U/L (normal, 88-196) and alkaline phosphatase 113 U/L (normal, 16-95). CT scan of the chest revealed emphysema and mult iple bilateral pulmonary nodules with cavitation (Fig. 1b). A low atte nuation region in the spleen was interpreted as representing an inflam matory or infectious focus, or, less likely, a cyst. CT scan of the ab domen revealed a normal liver and no abdominal adenopathy. Bone scan a nd ophthalmologic examination revealed no evidence of bony or ocular i nvolvement. A 4-mm punch biopsy from the plaque on the wrist revealed suppurative granulomatous inflammation extending from the lower papill ary dermis down to the deep dermis at the base of the biopsy specimen (Fig. 3a). Many multinucleated giant cells were observed. The overlyin g epidermis showed slight acanthosis with compaction and focal paraker atosis of the stratum corneum. In the dermis, numerous rounded structu res and septate hyphae, measuring 5-9 microns in diameter, were presen t both within giant cells and extracellularly (Fig. 3b). These structu res were stained by a Grocott methenamine silver stain, consistent wit h fungi (Fig. 3c). These findings, and the lack of encapsulation typic ally seen in subcutaneous phaeohyphomycosis, suggest a systemic fungal disease rather than direct cutaneous inoculation.(8) A second specime n was sent for culture to the University of Texas Health Science Cente r in San Antonio and grew Alternaria alternata (no further description is available). In retrospect, the pigment seen clinically may have re sulted either from the fungus, which is typically pigmented, or from a n ecchymosis. Sensitivity testing revealed that the fungus was suscept ible to amphotericin 0.29 mu g/mL, itraconazole 0.07 mu g/mL, and keto conazole 0.1 mu g/mL. Serum titers for complement-fixing antibodies to aspergillus and blastomyces were negative. Although no specific antif ungal therapy was started, follow-up chest X-rays showed a dramatic de crease in the size of the pulmonary nodules (Fig. Ic). During the same week, the plaque on the arm also decreased in size to 2.7 x 1.4 cm. T he alkaline phosphatase decreased to normal and the lactate dehydrogen ase decreased to 261. The patient was discharged home without antifung al therapy, and prednisone was discontinued 10 days after discharge. T he skin lesion resolved spontaneously. In the 2 years since presentati on there has not been a recurrence of skin or lung lesions.