The n e w e ng l a n d j o u r na l
Images in Clinical Medicine
Thomas Gliddon, M.B., B.S.
Kate Proudmore, M.B., B.S.
Sir Charles Gairdner Hospital
Nedlands, WA, Australia
kate.proudmore@health.wa.gov.au
580
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Copyright © 2019 Massachusetts Medical Society. All rights reserved.
of m e dic i n e
Chana A. Sacks, M.D., Editor
Cutaneous Malakoplakia
A B
A
53-year-old man who had undergone both liver and kidney
transplantation within the previous 2 years presented to the infectious
diseases clinic with a 4-month history of progressively enlarging, painless
nodules on his scalp (Panel A) and perianal region. He otherwise felt well. The
immunosuppressive medications that he was receiving included tacrolimus, myco-
phenolate mofetil, and prednisolone. Four weeks before the development of the
skin lesions, he had received pulse methylprednisolone for acute cellular rejection
of the transplanted kidney. Biopsy of the lesions identified Michaelis–Gutmann
bodies (basophilic inclusions) (Panel B, arrow), and cultures grew Escherichia coli
and Pseudomonas aeruginosa. A diagnosis of malakoplakia was made. This rare
chronic granulomatous condition, which occurs most frequently in immunocom-
promised patients, is thought to be due to defective intracellular killing of bacteria.
It is characterized by focal inflammatory lesions with Michaelis–Gutmann bodies
within macrophages. Cutaneous involvement is rare; the more typical presentation
involves the kidney or bladder. Management combines prolonged antibiotic therapy,
immunosuppression reduction, and sometimes surgical excision. The patient was
treated with antibiotics, including ciprofloxacin, along with a concurrent reduction
in immunosuppression. After 6 months of treatment, the lesions regressed, with
some residual scarring.
DOI: 10.1056/NEJMicm1809037
Copyright © 2019 Massachusetts Medical Society.
n engl j med 380;6 nejm.org February 7, 2019
The New England Journal of Medicine