C a s e R e p o r t e64 I NTRO D U C TIO NPyrenochaeta romeroi (P. romeroi) is a saprophytic fungus widely distributed in the environment; it can be found on wood and in plants.(1) The fungal spores of P. romeroi can be inoculated into deeper tissues by trauma, (2,3) and are a rare cause of skin and subcutaneous tissue infections. Herein, we report Singapore's first case of P. romeroi infection involving a 55-year-old renal transplant recipient who developed a chronic necrotising granulomatous skin lesion. The challenges involved in the diagnosis and treatment of this uncommon disease is discussed in this report. CA S E R EPO RTA 55-year-old Chinese man presented to our institution with a slow growing, painless nodular lesion on his left posterior thigh. One year before the current presentation, the patient had undergone a living related donor renal transplantation.For the transplantation, the patient received cyclosporine and thymoglobulin at induction, followed by maintenance immunosuppressive therapy with prednisolone 10 mg once daily, mycophenolate mofetil 250 mg twice daily, and cyclosporin 45 mg once daily. He had an uneventful postoperative recovery, and his transplanted kidney was found to be functioning well with no signs of rejection during follow-up.He did not have diabetes mellitus or a medical history of note, and he denied any history of trauma, soil exposure or participation in gardening activities. Throughout that one year (from renal transplantation to the current presentation), the patient did not show any systemic symptoms and his inflammatory markers (white cell count and C-reactive protein)were unremarkable. For his current presentation, the patient underwent ultrasonography of his left posterior thigh lesion, which revealed a thick-walled cystic mass. Histologic examination of the biopsied specimen showed necrotising granulomatous inflammation with fungal hyphae.The thigh lesion recurred and progressed despite repeated attempts at complete surgical excision over a one-year period. In vitro antifungal susceptibility test was performed, but the results were inconclusive because the fungus failed to grow well in the susceptibility testing medium. Nevertheless, the interpretation of the susceptibility data of this unusual mould (P. romeroi) would be difficult because there was no standardised susceptibility data for moulds other than those of the Aspergillus genus. The patient was started empirically on itraconazole syrup 200 mg twice daily for a period of two years. There was gradual reduction of the lesion size and the lesion remained quiescent in those two years. Throughout the course of treatment, itraconazole serum level was not monitored due to the unavailability of the test at our centre. ABSTRACT An infective aetiology, including fungal infection, should be considered in the differential diagnosis of immunocompromised patients presenting with skin lesions. Dematiaceous fungi are recognised as pathogens in organ transplant recipients. Herein, we describe a rare case of a chronic necrotis...

Multidrug-resistant Salmonella is a well-recognised problem worldwide, especially in developing countries such as India, where non-typhoidal Salmonella infections and enteric fever are endemic. Antimicrobial resistance, particularly to fluoroquinolones, is common and leads to the frequent use of alternative agents, such as azithromycin. We herein describe the first reported case of azithromycin-resistant Salmonella gastroenteritis in a Singaporean patient.

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