Answer to last month's Clinical Quiz

Question:

This is a 40 years old patient with end-stage chronic renal failure secondary to diabetic nephropathy. He had a successful renal transplant operation three months prior to the skin eruption. He was put on immuno-suppressant therapy and systemic steroid for control of graft rejection. Increasing number of slightly itchy papules and nodules were noted on the right cheek of this patient for the previous two weeks. They were progressive and extended towards the centre of face and nose.

Answer: A. Trichophytic granuloma

Infection must be excluded from a rapidly progressive rash presenting asymmetrically in an immuno-compromised patient. On further examination, this patient has extensive superficial fungal infection of feet and groin. Biopsy of one of the nodules had found folliculitis with deep-seated fungal hyphae in the perifollicular area. Fungal culture confirmed the presence of Trichophyton rubrum - a common pathogen for tinea pedis and tinea cruris in this locality. Trichophytic granuloma or perifollicular granulomatous papules of the Majocchi type are more commonly found in the hairy region of the lower limbs. It is also called nodular granulomatous perifolliculitis or Majocchi's granuloma. It represents an uncommon intradermal infection with follicular lesions by dermatophytes. Patients on systemic or topical steroid therapy are more prone to develop this condition. Granuloma-like lesions in immuno-compromised patients can be a result of different common infections with atypical presentations. Hence skin biopsy with microbiological investigations is always needed to identify the aetiology. Drug eruption is usually more widespread and symmetrically distributed. Kaposi sarcoma and granuloma annulare do not match with the rapid sequence of development of the lesions and the location of the rash.