Cutaneous alternariosis in a patient with idiopathic pulmonary fibrosis

A 78-year-old farmer presented with symptomless skin lesions for evaluation . Two years prior, he had developed idiopathic pulmonary fibrosis (IPF) and had been treated thereafter with oral prednisolone 20 mg/day and occasiona lly with colchicine 1 mg/day. On examination, erythematoviolaceous, slightly infiltrated plaques, measuri ng approximately 5 x 9 cm, rubbery in consistency, intermingled with pustul es, sometimes eroded, with distinctive borders, were noted on the dorsum of both hands and on the extensor surface of both forearms. The lesions had d eveloped over a 20-day period. The skin of these areas was atrophic or erod ed with multiple ecchymoses (Fig. 1). The abnormal laboratory findings included an elevated white blood cell coun t of 17,100/mm(3), with 79% neutrophils, 16% lymphocytes, and 5% monocytes, C-reactive protein of 33.15 mg/dL (normal, <0.8 mg/dL), and immunoglobulin G of 598 mg/dL (normal, 701-1545 mg/dL). Other blood and urine tests perfo rmed were within normal limits. The diagnosis of IPF was reconfirmed throug h radiology, high-resolution computed tomography, and spirometry, as well a s bronchoscopy and bronchoalveolar lavage fluid analysis. Coexistence of pr esumptive pulmonary alternariosis was excluded. Hematoxylin and eosin stained sections of the excised cutaneous specimen sh owed focal ulceration of the epidermis adjacent to a mainly intradermal abs cess cavity. Within the latter, remnants of a partly destroyed hair follicl e were seen amongst degenerating polymorphonuclear leukocytes, as well as m any histiocytes and a few Langhans-type multinucleated giant cells. Minute collections of polymorphonuclear leukocytes were seen in the adjacent epide rmis. Periodic acid-Schiff (PAS) and Gomori's silver methenamine stains sho wed a multitude of broad branching fungal hyphae and large spores within th e aforementioned cavity, both free and within the cytoplasm of giant cells (Fig. 2). Immunohistochemistry was performed by means of the alkaline phosp hatase anti-alkaline phosphatase (APAAP) method. Sections showed that the i nfiltrate consisted of an almost equal number of B and T lymphocytes, where as histiocytes and the few giant cells were labeled with anti-CD68 antibodi es. Skin smears and biopsy specimens taken twice from all lesions were used for mycologic examination. Wet mounts revealed numerous, brownish, septate hyp hae and ovoid Skin smears and biopsy specimens taken twice from all lesions were used for mycologic examination. Wet mounts revealed numerous, brownis h, septate hyphae and ovoid structures. Biopsy material was plated on Sabou rand's dextrose agar with cloramphenicol (0.05 mg/mL). After 7 days at 27 d egrees C, dark, gray-white colonies with a dark brown underside appeared. M icroscopic examination of the colonies revealed hyphae with typical conidia having transverse and longitudinal septa. Based on macroscopic and microsc opic examination, the isolates were identified as Alternaria alternata (Fig . 3). Treatment with prednisolone was reduced to 10 mg/day and the patient receiv ed oral itraconazole (200 mg/day). This resulted in progressive improvement of alternariosis, and the lesions healed completely within 3 months, when treatment was interrupted. Two years later, there is no evidence of recurre nce.