Multiple ring enhancing lesions in brain due to disseminated Zygomycosis in a renal transplant recipient.

A 24-year-old man underwent renal transplantation forchronic glomerulonephritis leading to end stage renaldisease. His mother was the donor. He was initiated ontacrolimus, 0.1 mg/kg per day, mycophenolate mofetil,1.0 g bds, prednisolone, 0.3 mg/kg per day and antihyper-tensives. His serum creatinine reached 1.1 mg/dL on the fifthpostoperative day. When the adhesive plaster applied to theright thigh to anchor the urinary catheter was removed itresulted in a 3 ¥ 2 cm sized ulcer. The ulcer was regularlycleaned and dressed. After the first month he presented to uswith complaints of lack of appetite, weight loss, malaise,head ache and body pains. The ulcer on the right thigh hadthe now increased in size to 10 ¥ 5 cm (Fig. S1). It wascovered with black and thick slough, margins were welldemarcated and had black coloured induration around it. Hisblood pressure was 110/80 mm Hg and systemic examina-tion was unremarkable except for neck stiffness. The inves-tigations done then were: serum creatinine: 1.1 mg/dL,blood urea: 24 mg/dL and chest radiograph was normal. Amagnetic resonance imaging brain scan revealed multiplering enhancing lesions in the parieto-frontal, occipital(Fig. 1) and cerebellar lobes (Fig. S2). Cerebrospinal fluidanalysis revealed: three leucocytes per high power field(hpf), glucose: 34 mg/dL, proteins: 45 mg/dL, India inkstaining and capsular antigen by latex agglutination andenzyme immune assay for crpytococcus were negative,adenosine deaminase was 8 U/L– not suggestive of tubercu-losis and polymerase chain reaction of cerebrospinal fluidsample for the detection of mycobacterial DNA was negative.The blood cultures and urine cultures were sterile. The pusand the tissue samples from the ulcer on the right thigh hadshown growth of