Cutaneous infection with Scedosporium apiospermum in a patient treated with corticosteroids.

A 64-year-old man was referred with a 3-month history of 2 contiguous subcutaneous, non-in ̄ammatory painless nodules on the back of his right elbow (Fig. 1). His health was good on admission. The skin in this area was thin, fragile and atrophic, with numerous ecchymotic lesions. Cutaneous biopsy of 1 nodule showed a granulomatous dermal in®ltrate with giant cells. Periodic AcidSchiff staining revealed intraand extra-cellular spores and septate hyphae. Oral ketoconazole was prescribed for 3 weeks. Six months later, cutaneous examination showed 4 new non-in ̄ammatory nodules on the right elbow, adjacent to the biopsy scar. Further biopsy showed a similar pattern to the ®rst, and culture on Sabouraud's agar revealed colonies of Scedosporium apiospermum. Serum tests for scedosporiosis were negative. The patient was retired, and undertook some gardening, but the mould was not found in the soil or vegetation in the patient's garden. The patient was treated with oral itraconazole (400 mg twice daily) for 1 month. Six months later, the remaining nodules appeared atrophic and no other lesion had appeared. The patient had a previous history of systemic sarcoidosis with initial hypercalcaemia, granulomatous nephropathy, hepatitis and cytopenia that had been treated with prednisone for 18 months. The initial dose of 1 mg/kg/day was progressively tapered, without relapse during the ®rst year, but then the dose was increased again because of recurrence of the disease. The dose was 0.2 mg/kg/day at the ®rst occurrence of cutaneous nodules and 0.5 mg/kg/day at the second. Humoral immunity was preserved, with normal immunoglobulins levels (IgA 2.36 g/l, normal 1.06 ± 3.39 g/l; IgG 8.20 g/l, normal 6.50 ± 12.10 g/l; IgM 2.32 g/l, normal 0.52 ± 1.48 g/l). The lymphocyte count was 1 336 g/l, with normal CD4 and CD8 counts (908/mm3 and 415/ mm3, respectively). Chest X-ray and computed tomodensitometry of the chest were normal. HIV-testing was negative.