Cutaneous Paecilomyces lilacunis infection in a hospitalized patient taking corticosteroids
Authors: Marchese Sandra M. , Smoller Bruce R. 
Published: March 2003

A 72‐year‐old Caucasian man presented with tender, hyperkeratotic, violaceous,ill‐defined, scattered plaques associated with minimal pitting edema of the right upper extremity. He had been discharged 3 days earlier from an outlying community hospital after a 33‐day admission for exacerbation of chronic obstructive lung disease requiring large doses of systemic corticosteroids. A right subclavian central venous line for intravenous access was placed after he developed a gastrointestinal bleed and myocardial infarction. The clinical differential diagnosis of the eruption on the right upper extremity at the time he presented to our service included cellulitis, deep venous thrombosis, and brachial plexus neuropathy. Brachial plexus neuropathy was ruled out with normal electromyography, nerve conduction studies, and cervical spine radiographs. Deep venous thrombosis was never completely eliminated, because the patient refused a venogram and the venous Doppler exam was nondiagnostic. Treatment for a presumed bacterial cellulitis was initiated with Nafcillin intravenously. As there was clinical disease progression without appreciable improvement by day nine ( Fig. 1 and 2), a skin biopsy was performed and topical Nystatin powder was added for possible yeast etiology. Bacterial cultures were negative; however, fungal cultures on Sabouraud’s agar were positive for Paecilomyces lilacunis after 15 days. Histologic sections demonstrated skin with an essentially normal epidermis. Within the dermis, there was an extensive, mixed, granulomatous inflammatory infiltrate with abundant multinucleated giant cells. Necrosis was not abundant. Occasional 8–12 μm yeast‐like organisms were apparent within the cytoplasm of multinucleated cells and in an extracellular location, together with occasional hyphal forms with irregular branching. Periodic acid–Schiff (PAS) with diastase and Gomori methenamine silver accentuated the staining and confirmed the fungal nature of the organisms (
Fig. 3). The histologic differential included various other fungi. Cryptococcus is usually smaller, endospores characteristic of coccidiomycosis were not present, and a thick capsule usually seen in blastomycosis was not observed in these organisms. The diagnosis of Paecilomyces lilacunis was established, and itraconazole 200 mg orally twice a day was instituted. Clinical improvement as measured by decreased edema, increased range of motion, and resolution of cutaneous lesions was dramatic during the first week. Itraconazole was decreased to 200 mg a day and the patient continued to improve. He was discharged to home. He has followed up in our clinic every month with complete resolution to date 7 months after discharge.Right upper extremity demonstrating violaceous hue, edema, and scale taken after 9 days of Nafcillin. Note progression of disease to involve the left upper extremityimageCloser view of right upper extremity showing tremendous scale. There is suture where the biopsy was performedimageGomori methenamine silver stain reveals multiple 8–12 μm organisms. Original magnification, 400×image