P137 Remote inoculation mycosis: Rip Van Winkle wakes up

POSTER SESSION 2, SEPTEMBER 22, 2022, 12:30 PM - 1:30 PM: OBJECTIVE: After immunosuppression, a remotely inoculated organism may be activated to produce clinical disease. We describe such a case with infection due to Medicopsis romeroi, a rare mold. PATIENT AND METHODS: A 54-year-old male, diabetic, hypertensive, status post-live related donor renal transplantation, done in February 2021. The patient was on standard triple immunosuppressant regimen. He developed a painless nodule on his thumb over 5 months which did not respond to multiple courses of antibiotics. The swelling was excised and sent for various tests. Review of USG after infectious disease referral, showed a small foreign body, like a wooden splinter in the wall of the lesion (Fig. 1). On inquiry, a 3 mm wooden splinter in the lesion was noted during surgery and there was an injury at the same site, 20 years ago when the patient used to work on a farm. Organisms derived from soil or thorn injury including bacterial and fungal organisms were considered in the differential diagnosis. Bacterial organisms were considered less likely as there was no response to antibiotics. RESULTS: Histopathology showed brownish septate hyphae with constrictions at the areas of septations (Fig. 2). The excised tissue grew a dematiaceous mold. In Lactophenol Cotton Blue (LPCB) mount branched, septate hyphae with sparse conidia were seen. MALDI- TOF MS was unable to identify the mold. Sequencing identified it as M. romeroi. There are no ECOFFs or break points (BP) available for M. romeroi. Minimum inhibitory concentration (MIC) of Voriconazole (VCZ) is reportedly low and hence was chosen for treatment with an appropriate dose adjustment of Tacrolimus. CONCLUSION: This case underscores that remote inoculation, when the patient was immunocompetent, could have introduced a mold, which remained latent and reactivated after immunosuppression. Sending excised tissue for appropriate tests is rewarding. Medicopsis romeroi is a rare mold with only 12 cases reported so far. It is difficult to identify except with sequencing. There is no standard guidance on treatment. Surgical excision along with prolonged treatment with one of the new azoles is beneficial.