Clinical Review
Cutaneous alternariosis in transplant recipients: Clinicopathologic review of 9 cases

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Objectives

We sought to evaluate and review the clinical and histopathologic features of cutaneous infections caused by the environmental opportunistic fungus Alternaria observed in transplant recipients.

Methods

We conducted a retrospective study of cases of cutaneous alternariosis in transplant recipients given a diagnosis in 3 hospitals in Catalonia, Spain, between 1991 and 2001. The clinical and evolution features were reviewed. A panel of histopathologic features was evaluated by two independent observers in all cutaneous biopsy specimens.

Results

In all, 9 transplant recipients (8 men and 1 woman) presenting opportunistic cutaneous alternariosis were studied. The patients were 4 renal, 2 cardiac, 1 liver, and 2 lung transplant recipients. All patients were treated with different immunosuppressive therapeutic regimes. The lesions were solitary (3 patients) or multiple grouped (6 patients): papules (4 patients), plaques (5 patients), inflammatory nodules (2 patients), and recurrent cellulitis with secondary ulceration (1 patient), mainly located on the lower extremities. No extracutaneous involvement was detected. A previous traumatic event was recorded in two patients. A total of 12 cutaneous biopsy specimens were reviewed. Biopsy specimens from early lesions (<3 months evolution) were often characterized by the presence of epidermal changes (3/6 pseudoepitheliomatous hyperplasia; 50%), a diffuse dermal mixed inflammatory infiltrate of lymphocytes, plasma cells, histiocytes, neutrophils, and giant cells, and rare and focal granuloma formation. Dermal abscess or necrotizing folliculitis was occasionally noted. In biopsy specimens from more advanced lesions (>3 months evolution), the presence of a granulomatous inflammatory infiltrate was a constant feature. Suppurative granulomas (2/6; 33%) and sarcoidlike granulomas (2/6; 33%) were noted. In all biopsy specimens, fungal structures with a typical round-to-oval, thick refractile wall were identified.

Conclusion

Different clinical and histopathologic patterns can be noted in cutaneous alternariosis. Clinically the lesions manifest as solitary or grouped papules, plaques, or nodules mainly involving the lower extremities. Histologically, a relationship between the evolution of the cutaneous lesions and granuloma formation is detected. An increased awareness regarding the clinical and histopathologic features of cutaneous alternariosis in transplant recipients is important to achieve early detection and treatment.

Section snippets

Patients and methods

In a retrospective study from 1991 to 2001, the clinical files of solid organ transplant recipients were reviewed from 3 hospitals in Catalonia, Spain, and those patients given the diagnosis of cutaneous alternariosis were selected.

Following a systematic protocol, the records of patients were evaluated regarding epidemiologic and clinical data using the following criteria: immunologic status and associated diseases, possible source of infection, elementary lesions (nodules, papules, pustules,

Clinical features

Eight men and one woman given the diagnosis of cutaneous alternariosis were studied. The age of patients ranged from 27 to 67 years. All patients were recipient transplants and were following different immunosuppressive treatment regimens (Table I). Three renal transplant recipients were treated with corticosteroids and azathioprine; corticosteroids, azathioprine, and cyclosporine; and corticosteroids, tacrolimus, and mycophenolate mofetil, respectively. In one renal transplant recipient the

Discussion

Alternaria species are dematiaceous ubiquitous fungi present in the air, soil, and plants. Alternaria species are rarely invasive in humans, being more often recognized as a well-documented human allergen in the origin of asthma or as a mold on fruits. Hypersensitivity pneumonitis secondary to inhalation of the spores has occasionally been reported.5 Nevertheless, Alternaria acts as a facultative pathogen, especially when an impairment of the immune system is present, and it can cause a wide

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    Funding sources: None.

    Conflicts of interest: None identified.

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