Alternariosis is an opportunistic fungal disease developing most commonly in immunocompromised patients [1]. Although a few cases of deep-seated infections have been described, the disease is usually confined to the skin [2]. Proposed treatments consist of systemic administration of amphotericin B or imidazole compounds [3].

We report the case of a 50-year-old woman who received a renal allograft in 1991. Immunosuppression was maintained with cyclosporine, azathioprine, and prednisone. One year after the transplantation and 2 months after a local trauma, a purple, crusted, Kaposi-like, painless lesion of the leg developed (Figure 1). Histologic examination showed a granulomatous infiltrate of the upper dermis surrounding septate hyphae that were periodically acid-Schiff-positive in histiocytes. The fungus was identified in culture as related to the genus Alternaria. Serologic results were positive (100 kU/L; normal, <0.75 kU/L). Other tests showed no visceral extension.

View larger version (174K): [in this window] [in a new window]   Figure 1. Kaposi-like crusted lesion of the inner side of the left leg, measuring 4 x 3 cm.

The usual treatments were not effective. Local excision was technically difficult because of the size of the lesion and the risk for septicemia. Systemic amphotericin B or imidazole compounds such as ketoconazole or itraconazole would increase the cyclosporine blood levels and seriously affect the renal function [4].

Because of the solely cutaneous localization of disease and the impossibility of reducing the dose of cyclosporine, we initiated daily occlusive local application of ketoconazole. The lesion healed within 2 months and did not relapse in 18 months of follow-up despite continuation of immunosuppressive therapy. The cyclosporine blood levels remained unchanged, suggesting that locally applied ketoconazole was not systemically diffused.

We propose this treatment for cutaneous alternariosis in patients who have received transplants. Because deep-seated infections are rare, local therapy can be used without any systemic risk. In addition to the lower cost of this treatment, interactions with other drugs can be avoided.