Invasive Trichophyton rubrum resembling blastomycosis infection in the immunocompromised host

A 55-year-old renal transplant recipient with onychomycosis and chronic tinea pedis presented with tender nodules on his left medial heel. He then developed papules and nodules on his right foot and calf. A skin biopsy demonstrated periodic acid-Schiff (PAS) positive, thick walled round cells, 2 to 6 microm in diameter, in the dermis. Skin biopsy culture grew Trichophyton rubrum. T. rubrum has been described as an invasive pathogen in immunocompromised hosts. The clinical presentation, histopathology, and early fungal culture growth suggested Blastomyces dermititidis in the differential diagnosis before the final identification of T. rubrum.