h Paraconiothyrium cyclothyrioides is a recently described coelomycetous fungal species. We present a case in a renal transplant patient with chronic skin lesions of the lower extremities caused by P. cyclothyrioides. Treatment with posaconazole led to complete resolution of the lesions. P. cyclothyrioides should be considered an opportunistic human pathogen in immunocompromised patients. CASE REPORTA 49-year-old Latin American man with end-stage renal disease and a cadaveric renal transplant (2 years prior to the current admission) was hospitalized with cutaneous lesions in his lower extremities. The patient had history of type II diabetes, hypertension, and atrial fibrillation. One and half years previous to admission, the patient received thymoglobulin for acute T-cell rejection, with improvement of the episode. Approximately 6 months before the current admission, the patient first noticed a painless, nonpruritic, mildly tender scaly papule on the left tibia just inferior to the knee joint and applied a local adhesive band to prevent friction injury. Over the next few months, other lesions appeared on both tibial surfaces which then began to coalesce into violaceous, necrotic, plaque-like lesions with some areas of ulceration and crusting and mild self-limiting sanguineous discharge without accompanying fevers. The patient lives in Brownsville, TX, works in an office as a manager, and denied any travel outside Texas, trauma, or animal or insect bites. The patient's hobbies include performing mechanical work on car engines. Medications included leflunomide, prednisone, tacrolimus, doxazosin, clonidine, carvedilol, minoxidil, amlodipine, trimethoprim-sulfamethoxazole, insulin, famotidine, gemfibrozil, and pravastatin. His complete blood count was notable for a platelet count of 73 and creatinine of 2.4 mg/dl. On physical examination, he was afebrile and vital signs were stable. A cardiac examination evidenced an irregular rate and a II/VI murmur loudest in the apex. The lungs were clear, and the rest of the examination was unremarkable except for the lower extremities. He had a crusted, ulcerated plaque on the anteromedial aspect of the left knee (measuring 6 by 3 cm) and several similar-appearing lesions of smaller size on the same area (Fig. 1A). The patient was started on vancomycin (1.25 g every 24 h); radiographs of the knee did not reveal any bone abnormality. A skin biopsy specimen yielded a presumptive diagnosis of pyoderma gangrenosum, antibiotics were stopped, and the patient was discharged with wound care instructions and silver sulfadiazine.Two months prior to the current admission, a fungal culture from the skin tissue was positive for a single mold which grew on Sabouraud dextrose (Sab Dex) agar but was not identified at the time. Oral voriconazole (200 mg orally every 12 h) administration was initiated. A month after his discharge, he presented to the dermatology clinic with evidence of progression of his skin lesions and was again admitted to the hospital. He denied new recent trauma or travel h...

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Herpes zoster, also known as shingles, occurs upon reactivation of a primary infection with varicella zoster virus (VZV). Risk factors for reactivation include stress, older age, and immunosuppression, all of which are associated with a decrease in host immunity. Common complications of herpes zoster include scarring and post-herpetic neuralgia (PHN). Cutaneous lesions such as granuloma annulare, lymphomas, and sarcoid granulomas have also been reported to potentially arise at the site of herpes zoster. Here, we report a case that to our knowledge is the first presentation of diffuse large B-cell lymphoma with its only cutaneous manifestation arising in a herpes zoster scar. Punch biopsy was performed on a nodule appearing in a dermatomal distribution within the herpes zoster scar. Histopathology revealed an atypical lymphoid infiltrate in the dermis that was determined to be CD20 positive B-cells. Immunostains for CD20, CD79a, and PAX-5 showed strong positive staining of the atypical cells, confirming B-cell origin and resulting in the diagnosis of lymphoma, large B-cell type. This case highlights the importance of raising clinical suspicion for a malignant process in patients who present with a changing or unresolving skin manifestation after infection with varicella zoster virus.

The Papanicolaou (Pap) test category of "low grade squamous intraepithelial lesion, cannot exclude high grade squamous intraepithelial lesion" (LSIL-H) is not recognized by The Bethesda System but is commonly used. It is essentially an amalgamation of the official LSIL and ASC-H categories. Since these two categories have similar follow-up algorithms, the clinical utility of the combined LSIL-H category is unclear. We have therefore studied follow-up patterns for these three entities in our laboratory to determine the real-world impact of each in our patient population. We searched our pathology database over an 18-month period to find Pap tests (predominantly ThinPrep) interpreted as LSIL-H (137), LSIL (2,189), and ASC-H (101). Like other studies, we found that the discovery rate of high grade dysplasia in biopsies after LSIL-H (31.9%) was similar to ASC-H (35.3%) and was higher than LSIL (7.6%; P < 0.0001). In women with no previous history of dysplasia, the frequency of biopsy follow-up after the initial Pap test was significantly higher for LSIL-H (68.3%) than for LSIL (49.6%; P = 0.0038) and similar to ASC-H (62.3%). We also found that women with an initial negative biopsy or a biopsy positive for low grade dysplasia were more likely to undergo an additional biopsy if the initial Pap test was LSIL-H (36.2%) than if it was LSIL (18.2%; P = 0.0023). ASC-H (26.9%) had an intermediate rate. In our patient population, the use of the terminology LSIL-H is associated with follow-up biopsy patterns much more similar to ASC-H than to LSIL.

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