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Swelling of a Finger in a Renal Transplant Recipient

Published:December 21, 2020DOI:https://doi.org/10.1016/j.amjmed.2020.10.047
      A 52-year-old woman presented with a 5-month history of painless swelling of a non-dominant hand finger, without contributing factors such as trauma. Past medical history was notable for diabetes mellitus with glycated hemoglobin level of 7.9%, and autosomal dominant polycystic kidney disease that required a kidney transplant 1 year earlier. She was receiving immunosuppressive maintenance therapy with prednisone (10 mg daily), tacrolimus (with targeted trough level between 5-7 ng/mL), and mycophenolate mofetil (1000 mg daily). Clinical examination revealed a fluctuant nodule (measuring 15 × 10 mm) of the palmar surface of the left index (Figure). There was no fever, no argument for a deep infection such as a flexor tenosynovitis, nor regional adenopathy. Clinical examination was otherwise unremarkable.
      Figure
      Figure(A) Fluctuant nodule of the palmar surface of the first phalanx of the second finger. (B) Magnetic resonance T2-weighted imaging: nodular lesion facing the flexor tendon with high signal intensity. (C) Histological study: central necrotic cavity surrounded by chronic inflammation and fibrosis at low magnification (hematoxylin and eosin staining; scale bar: 2 mm). Insert: silver staining shows fungi forming vesicular mycelium in the central necrotic area (Grocott silver stain; scale bar: 200 µm).
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