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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Title
Legend
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Necrotic lung tissue in culture
Af=Colony of Aspergillus fumigatus
B=bacterial colonies
L=lung tissue
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A photograph of part of the upper lung lobe of an immunosuppressed patient. The lung tissue shows extenive areas of necrosis due to invasive colonisation.
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A photograph of a cavity in the upper lobe of the lung of a patient with ankylosing spondylitis. Such cavitation,which may be confused with prior tuberculosis, can follow fibrosis.
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Plugs stained with Methenamine/silverActively growing mycelia of the fungus are a deep brown/black. Counterstaining shows the dense mucus of the plugs as predominantly orange.
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Sputum from an asthmatic patient showing plugs(casts). The development of plugs coincided with an increased prevalence and severity of episodes of asthma
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microscopic characters Conidiophore stipes(C)1300-2800um long:Vesicles(V)40-70um wide,clavate:Phialides(Ph) uniseriate:Conidia(Con)3.5-4.0um long,smooth walled.
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microscopic characters Conidiophore stipes(C)225-350um arising from hyphae(Hy):Vesicles(Ves)15-25um wide:Phialides(Ph)uniseriate:Conidia(Con)2.4-3.0um spherical to ovoid,roughened.
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