One of the most prevalent species of this group is (7, 20). antibodies. Liver biopsy revealed a profound destruction of liver architecture, fibrosis, active inflammation, and cholestasis. Treatment with steroids was followed by a good clinical response and normalization of liver enzymes. Attempts to wean the patient from steroids including administration of azathioprine and cyclosporine failed, and during the 2 years prior to admission he received both prednisone and cyclosporine. Several weeks before admission, he was evaluated for a chronic cough. He had undergone a transbronchial biopsy that disclosed chronic inflammation and thickening of the basement membrane, without any specific diagnosis, but responded to an increase of the dose of steroids. A few weeks later, while trying to taper the steroids, he developed multiple, hard cutaneous nodules, distributed mainly on the lower limbs. Some later softened and discharged caseous material spontaneously. Other underlying conditions included glucose-6-phosphate dehydrogenase deficiency, nephrolithiasis, benign prostate hypertrophy, bilateral inguinal hernia repair, and osteoporosis. On admission, medications included prednisone (10 mg once a day [QD]), cyclosporine (100 mg QD), ursodeoxycholic acid (300 mg twice a day), alendronate (10 mg QD), omeprazole (20 mg QD), and calcium (600 mg) and vitamin D (0.25 g) once daily. On physical examination, rhonchi were heard over both lungs. A few hard, mobile subcutaneous nodules were present on both lower limbs, mainly around the knees and thighs (Fig. ?(Fig.1a),1a), and the sacral area. Some of these nodules were purplish and soft. Onychomycosis was present on the feet and both hands (Fig. 1b and c). Open in a separate window FIG. 1. Clinical signs at admission. (a) Multiple firm APAF-3 nodules can be seen over the patella. A softer, purple nodule can be seen Carbazochrome on the thigh. (b) Onychomycosis of feet. (c) Onychomycosis of both hands. Laboratory test results were as follows: ESR, 80; hemoglobin level, 10.8 g/dl; leukocyte count, 7,900/l (42% granulocytes); albumin level, 34 g/liter; total protein level, 83 g/liter; liver enzyme levels, normal. Two of the patient’s nodules were excised. A granulomatous inflammatory reaction was present in the dermis and hypodermis. It was composed of monocytes, macrophages, multinucleated giant cells, and rare neutrophils (Fig. ?(Fig.2).2). Septate hyphae were revealed by both periodic acid-Schiff staining (PAS) and Gomori methamine staining (GMS) inside and outside the macrophages. Immunohistochemistry was performed by the avidin-biotin-peroxidase method (3, 22). Antibodies are listed in Table ?Table1.1. A majority of the inflammatory cell infiltrate was composed of Mac 387+ CD68+ macrophages, which outnumbered the CD45+ lymphocytes. Factor XIIIa+ dermal dendrocytes were present only in the surrounding connective tissue. Fungal hyphae were labeled by anti-and anti-antibodies (Fig. ?(Fig.2).2). Immunostaining for and spp. was negative. Open in a separate window FIG. 2. Histology of nodules. (a) Granulomatous reaction with many multinucleated cells (hematoxylin-eosin stain). (b) Typical Carbazochrome fungal hyphae within the granuloma (PAS stain). (c) Pleomorphic fungal hyphae as seen by GMS staining. (d) Immunohistochemistry with an anti-antibody showing intracellular hyphae. TABLE 1. Panel of antibodies spp.DakoAnti-spp.University of LigeAnti-spp.University of Lige Open in a separate window Specimens of pus and nodules were cultured on potato dextrose agar (Difco Laboratories, Detroit, Mich.). was identified according to its characteristic morphology on agar (Difco): granular white colonies with blood-red reverse and production of clavate to pyriform microconidia (5). This identification was confirmed by a PCR-based typing method that analyzes variations in numbers of repetitive elements in the nontranscribed spacer region of the rRNA gene repeats (Fig. ?(Fig.3)3) (11). This PCR test, using two different sets of primers, is specific for (and very closely related species such as type (11) (TRS1 type data not shown). This PCR failed to amplify any product from DNA extracted from the paraffin-embedded tissue. Open in a separate Carbazochrome window FIG. 3. PCR confirmation of the identity of the isolate. DNA was extracted from a colony and amplified with primers to detect the TRS2 type. M, molecular weight marker; lane 1, reference Carbazochrome isolate T4-12/12, TRS2 type I; 2, reference isolate T5-0/12, TRS2 type II; 3, case isolate, TRS2 type II. The patient was treated with itraconazole at 400 mg/day for 1 month, followed by 200 mg/day for two more.