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Multiple cysts in a renal transplant recipient.

To the Editor: Renal transplant is a boon for patients with renal failure as they escape the rigors of regular dialysis sessions. However, transplantation may lead to its own spectrum of skin problems that often present a diagnostic dilemma. The clinical picture may be modified by the concomitant immunosuppressive medications. We report a case of multiple cysts in a renal transplant recipient. A 45-year-old man presented with cystic lesions on the buttocks and arms of 2 years’ duration. Following a renal transplant, which was performed approximately 2.5 years prior, he received cyclosporine 200 mg daily, azathioprine 50 mg daily, and prednisolone 40 mg daily, which was subsequently tapered to 10 mg daily. The cysts started developing on the buttocks approximately 6 months after the transplant. Thereafter, new cysts appeared and old ones enlarged. Occasionally these lesions became red and tender. Incision and drainage was done and he was given antibiotics by the local practitioner. The lesions subsided but recurred after some time. Examination revealed multiple, flesh-colored, nontender nodulocystic lesions varying in size from 1 to 4 cm over the buttocks, thighs, and arms in a bilateral symmetric distribution (Figure 1). He also had a few multilocular cysts on the thighs (Figure 2). In addition, he had extensive tinea corporis and onychomycosis. Fine-needle aspiration cytology from one of the lesions revealed pultaceous material and the smear showed squamous cells; the findings were consistent with the diagnosis of an epidermoid cyst. The cysts were dissected bluntly from the surrounding tissue. The specimen sent for histopathology revealed cysts filled with horny material and lined by keratinized stratified squamous epithelium, suggestive of an epidermoid cyst. There was no evidence of malignancy or human papillomavirus (HPV) in the cyst wall or its contents. Cutaneous lesions can be a notable problem in transplant recipients. Factors such as climate and skin type have been implicated as modifiers of these clinical manifestations. Patients may develop cutaneous complications related to long-term immunosuppressive drug treatment. These complications are either related to immunosuppression such as common warts, dermatophytosis, premalignant lesions, and skin cancer, or drug-specific effects such as acne, rosacea, folliculodystrophy, and hypertrichosis. Epidermoid cysts are commonly encountered in routine dermatologic practice. The exact etiology of epidermoid cysts is unknown, but many factors such as trauma and occlusion of pilosebaceous follicles by HPV have been cited as etiologic factors.1 Although viral infections occur at an increased frequency in Multiple Cysts in a Renal Transplant Recipient