Date: 26 November 2013
This patient with ABPA and chronic cavitary pulmonary aspergillosis has been stabilized on voriconazole treatment for >5 years. She had a degree of photosensitivity most of that time, noticed early in the course of voriconazole treatment. She is oxygen and wheelchair dependent and doesn’t go outside very much, so most of her light exposure has been indoor light. She developed rough scaly patches over her face, neck and lower arms. Dermatological review indicated multiple solar keratoses”. Skin biopsy from the right forearm confirmed this clinical diagnosis – “skin showing hyperkeratosis with a little parakeratosis and acanthosis. The keratinocytes have a glassy appearance but show nuclear atypia with dyskeratotic cells, and occasional suprabasal mitoses. The intraepidermal sweat ducts are spared. Appearances suggest an actinic keratosis with moderate to severe dysplasia.” These features are characteristic of a low grade premalignant change.
She was treated with local 5-fluorouracil cream (Efudix) (3 cycles) to the affected lesions. These photos were taken at the apogee of inflammation. The inflammation resolved after discontinuing the cream. This reaction is expected with application of this mild chemotherapy agent. Alternative or supplementary treatments include cryotherapy, curettage and cautery, if necessary. Following treatment her skin was much softer and considerably improved. Voriconazole has been stopped, and posaconazole substituted.
Copyright:
DW Denning and JE Ferguson, University Hospital of South Manchester. 22/07/08
Notes: n/a
Images library
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BAL specimen showing hyaline, septate hyphae consistent with Aspergillus, stained with Blankophor
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Mucous plug examined by light microscopy with KOH, showing a network of hyaline branching hyphae typical of Aspergillus, from a patient with ABPA.
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Corneal scraping stained with lactophenol cotton blue showing beaded septate hyphae not typical of either Fusarium spp or Aspergillus spp, being more consistent with a dematiceous (ie brown coloured) fungus
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Corneal scrape with lactophenol cotton blue shows separate hyphae with Fusarium spp or Aspergillus spp.
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A filamentous fungus in the CSF of a patient with meningitis that grew Candida albicans in culture subsequently.
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Transmission electron micrograph of a C. neoformans cell seen in CSF in an AIDS patients with remarkably little capsule present. These cells may be mistaken for lymphocytes.
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India ink preparation of CSF showing multiple yeasts with large capsules, and narrow buds to smaller daughter cells, typical of C. neoformans
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