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JAMA Dermatology Clinicopathological Challenge
November 2018

Spiky Skin in a Renal Transplant Recipient

Author Affiliations
  • 1Department of Dermatology, Oxford University Hospitals NHS Foundation Trust, United Kingdom
  • 2Department of Cellular Pathology, Oxford University Hospitals NHS Foundation Trust, United Kingdom
JAMA Dermatol. 2018;154(11):1342-1343. doi:10.1001/jamadermatol.2018.1267

A woman in her 70s presented with a 1-year history of a facial cutaneous eruption initially affecting malar cheeks and eyebrows. Subsequently it spread to involve nose, chin, upper trunk, and extremities. The lesions were mildly pruritic. Her medical history included a cadaveric renal transplant 2 years earlier for end-stage renal failure. Immunosuppressant medications included mycophenolate mofetil, 200 mg, twice daily and tacrolimus, 8 mg, twice daily. Tacrolimus levels were therapeutic. Physical examination revealed multiple 1-mm flesh-colored follicular papules and keratin spines against a diffuse erythematous background affecting the face (Figure, A and B) and upper trunk. Her scalp and eyebrow hairs were unremarkable. Serology results were unremarkable. Results of skin biopsy from the right ear demonstrated dilatation and keratotic plugging of the hair infundibula with marked dystrophy and expansion of the inner root sheath. The inner root sheath cells were enlarged with irregular trichohyaline granules and apoptotic cells with abrupt cornification without formation of a granular layer (Figure, C). Immunohistochemical analysis for SV40 polyomavirus was positive (Figure, D).

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