The transplanted patient who suffered from excruciating lower limb pain and developed nodular skin lesions.

A 57-year-old man was admitted in May 1998 with a Skin lesion biopsy performed on D1 disclosed a 15-day history of moderate fever and tender subcutane-ous nodules and plaques on both thighs and legs. In lobular panniculitis with fat necrosis and infiltrating 1967 he underwent successful renal transplantation histiocytes, many of which had ingested red blood cells for end-stage renal disease (ESRD) due to chronic and lymphocytes. Epidermis and superficial dermis glomerulonephritis. No rejection episode occurred. were normal. This picture is pathognomonic of Maintenance immunosuppression included azathio-the so-called cytophagic histiocytic panniculitis prine and prednisolone. In January 1998 liver trans-(Figure 2) (1). plantation was performed for hepatocellular carcinoma Progressively, nodules on the right ankle turned complicating hepatitis C virus (HCV)-related cirrhosis. to ecchymotic vesicles and then became ulcerated. Tacrolimus was added to the immunosuppressive regi-Skin lesions became more and more painful and re-men. Two months later, intense HCV replication quired morphine administration. Methylprednisolone required a transient tapering of the immunosuppres-125 mg/day was given in association with ceftriaxone sion. In May 1998 he developed fever up to 38°C; nine 1 g/day (D9). The patient progressively lost con-blood cultures grew no organisms and CMV antigenae-sciousness, grand-mal seizures occurred and he died mia was negative. A few days later multiple painful on D 13. erythematous subcutaneous plaques appeared on both A second skin lesion biopsy performed on day 9, thighs (Figure 1) and extended progressively to the available after patient's death, revealed massive legs. On admission (D1), treatment included tacrol-Cryptococcus neoformans fungi invading dermis and imus 2 mg o.d, prednisolone 8 mg o.d, isradipine subcutaneous fat. Autopsy further disclosed the pres-2.5 mg o.d and furosemide 120 mg o.d. ence of C. neoformans within the skin, prostate, men-Physical examination revealed moderate ascites that inges, cerebral ventricles and cortex. Retrospective was known since the time of liver transplantation. The analysis of the first skin biopsy also revealed the rest of the examination was normal. presence of Cryptococci on some histological sections Laboratory tests showed: haemoglobin 12.3 g/dl, (Figure 2). white blood cell count 13.92×109/l (91.8% neutro-Cytophagic histiocytic panniculitis associates fever phils), platelets 243×109/l and a normal coagulation and subcutaneous nodules or plaques which may pro-screen, urea 154 mg/dl, creatinine 147.8 mmol/l, CRP gressively become ecchymotic and ulcerated. Diagnosis 3.2 mg/dl, fibrinogen 247 mg/dl, serum iron 28 mg/dl, relies on histological features of fat infiltration by ferritin 833 ng/ml, triglycerides 257 mg/dl, cryoglobu-benign-appearing histiocytes which have phagocytosed …