Late onset phaeomycotic cyst in a renal transplant recipient

A 50‐year‐old housewife presented with a swelling over the left knee joint of about 1 year's duration. She gave no history of local trauma. She had undergone a live renal transplantation 5 years previously for autosomal dominant polycystic kidney disease when she reached end‐stage renal disease. The postoperative period was uneventful and she was discharged on triple immunosuppression with Prednisolone, Azathioprine and Cyclosporine along with Co‐trimoxazole and antihypertensive therapy including Diltiazem. She had no episodes of graft dysfunction and continued to lead a normal life. On examination there was an oval 5 × 3 cm size suprapatellar swelling on the left side which was nontender and with no signs of inflammation ( Fig. 1). Except for the prepatellar bursitis, other physical findings were unremarkable. Renal function tests and other routine investigations were normal. She was not given any treatment at that time. She had good graft function. Triple immunosuppression was continued. Figure 1 Left sided suprapatellar swelling When she returned again for a follow‐up after 6 months, the swelling had increased in size to 8 × 5 cm. It was soft and fluctuant on palpation. Other systems were clinically normal. Her blood pressure was 140/100 mmHg. Investigations Haemoglobin : 9.4 g/dL. Blood urea nitrogen : 16.7 mg/dL. Serum Creatinine : 1 mg/dL. RBC count : 3.3 million/mm 3 . WBC count : 6400/mm 3 . Urine routine examination : Normal. Aspiration of the swelling was done by an orthopaedic surgeon and 50 mL of thick pus was drained aseptically in June 1998. Pus was sent immediately to the laboratory for culture and sensitivity. Gram‐stain showed plenty of pus cells and thick hyphael elements ( Fig. 2). In 10% KOH‐mount pale brownish, septate fungal elements were seen. Routine culture yielded no bacterial growth even after 48 h of incubation. Sabouraud's dextrose agar showed greyish‐black velvety compact colonies after 1 week of incubation at room temperature. On the reverse side, black pigmentation was seen ( Fig. 3). Lactophenol cotton blue preparation showed only septate hyphae. 2Gram stain of the pus showing fungal hyphae3Growth on Sabouraud's dextrose agar Slide culture by the conventional technique showed predominantly cladosporium‐type sporulation ( Fig. 4). Antifungal susceptibility was not done with the isolate. The patient was started on Itraconazole 200 mg orally twice daily and was asked to continue for 1 year. The culture was later identified as one of the dematiaceous fungi “Fonsecaea pedrosoi”. 4Cladosporium type of sporulation on slide culture The patient came for follow‐up after 6 months and she had recurrence of the swelling at the same site. History revealed that she had taken oral Itraconazole only for 1 month and she had discontinued therapy because of symptomatic improvement. Diagnostic aspiration was done again and since microscopy and culture showed the same fungus, she was advised to continue treatment with Itraconazole for 1 year. During follow‐up it was observed that the response to treatment was good.