title: A nodulo-cystic eumycetoma caused by Pyrenochaeta romeroi in a renal transplant recipient: A case report.
abstract: BACKGROUND
  Pyrenochaeta romeroi (P. romeroi) is a saprophytic fungus found in soil and plants. The fungal spores can be introduced into deeper tissues by trauma. It causes eumycetoma, which affects skin and subcutaneous tissues.
  
  
  METHODS
  A 57-year-old South Asian man presented with a painless, nodular lesion (1 cm × 0.5 cm) on the left knee. He had had a renal transplant eight months earlier for end-stage renal failure. The patient was on tacrolimus, mycophenolate mofetil and prednisolone for immunosuppression. The lesion had progressed dramatically (to 5 cm × 5 cm) despite antibiotic treatment. The size and location of the lesion was severely affecting his quality of life, so an excision biopsy was performed. Nuclear ribosomal repeat-region sequencing confirmed the causative organism as P. romeroi. An in vitro antifungal susceptibility test demonstrated that P. romeroi was sensitive to voriconazole. Following a successful surgical removal, voriconazole was continued orally for two months.
  
  
  CONCLUSIONS
  To the best of our knowledge, we are reporting the first case of Eumycetoma caused by P. romeroi in a renal transplant recipient. Physicians should be aware of this rare fungal disease in transplant recipients. We recommend a combination of medical and surgical management in these immunosuppressed patients.
authors.affiliation: Department of Infection, Immunity & Inflammation, Transplant Group, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, UK. umasurgeon@gmail.com.
authors.forename: Umasankar
authors.initials: U
authors.lastname: Mathuram Thiyagarajan
authors.forename: Atul
authors.initials: A
authors.lastname: Bagul
authors.forename: Michael L
authors.initials: ML
authors.lastname: Nicholson