1. Katherine Frasca Emily Blumberg University of Pennsylvania

2. Clinical Case 70 year old female with a history of idiopathic pulmonary fibrosis s/p left lung transplant (CMV +/+) presents with subacute skin lesions beginning 10 mos post transplant 1 month history of slowly progressive skin lesions starting in left thigh then spreading to buttocks, upper extremities Painful, raised, red to purple in color without itching/crusting or discharge No response to topical steroids PMH: Diabetes mellitus, Chronic kidney disease, native lung Aspergillus waksmanii – on chronic posaconazole Medications: Tacrolimus, Mycophenolate, Prednisone, Posaconazole, Trimethoprim sulfamethoxazole

4. H&E, 4x

5. H&E, 20x

6. Lab results 5/20: Skin biopsy #2 culture: +2 AFB smear Culture AFB: stain +4, + mycobacterium chelonae 5/17: Skin biopsy #1 culture: GS rare WBC, no bact, cx P, fungal stain neg/AFB smear neg Culture AFB: stain +4, + mycobacterium chelonae 5/17: Skin bx #1 pathology: + necrotizing granuloma FITE + acid fast bacilli, AFB/grocott/PAS neg 5/26, 27, 28: Sputum AFB smear neg, cultures pending 5/17: Sputum cx: cancelled (saliva) 5/17: Sputum AFB: smear neg, culture no growth 5/16: Fungal blood cultures: no growth 5/16: Blood cultures: no growth

7. Clinical course TTE negative, initial optho evaluation unremarkable Started on empiric treatment with azithromycin, linezolid and tobramycin but ultimately switched to clofazamine/azithromycin Within 5 days, large lesion on the left upper extremity, as well as most other lesions, showed dramatic improvement Eye lesion diagnosed as phlyctenular keratoconjunctivities