Case #16:

Clinical Presentation:
A 24 year-old man with a history of Systemic Lupus Erythematosis presents with disseminated pustulo-nodular skin lesions (Case 16 Image 1). His medications include Prednisone 20mg daily. Bacterial cultures of the lesions had no growth. Unroofed lesions exuded copious amounts of thick yellow exudate.

Clinical Diagnoses:
Staphylococcal pyoderma
Disseminated Herpes virus
Mycosis Fungoides (Cutaneous T Cell Lymphoma)
Nontuberculous Mycobacterial Infection
Systemic Mycoses

Case 16 Image 2: Giemsa stain of scrapings showing septate hyphae coursing through exudate.
Case 16 Image 3: Gram stain showing outline of fungal hyphae accentuated by purulent exudate abutting and delineating the hyphae.

Discussion:
Microbiologic Diagnosis:
Invasive Tricophyton Rubrum
This dermatophyte fungus can cause deep follicular invasive as well as systemic invasion in individuals who are immunosuppressed. Transmitted from person to person by direct contact and also soil to human.

On Sabouraud's media (Case 16 Image 4) colonies of Tricophyton rubrum are cottony and powdery. A reddish-purplish pigmentation develops on the underside of the colony.