Dermatology: Practical and Conceptual Image Letter | Dermatol Pract Concept. 2023;13(3):e2023166 1 Trichodysplasia Spinulosa in a 71-Year-Old Heart Transplant Recipient Maulik M Dhandha1, Debjit Ghosh2, James Dekay3 1 Woodland Clinic - Dignity Health, Woodland, CA 2 MGL Group, Rajkot, India 3 Maine General Medical Center, Augusta, ME Citation: Dhandha MM, Ghosh D, Dekay J. Trichodysplasia Spinulosa in a 71-Year-Old Heart Transplant Recipient. Dermatol Pract Concept. 2023;13(3):e2023166. DOI: https://doi.org/10.5826/dpc.1303a166 Accepted: January 25, 2023; Published: July 2023 Copyright: ©2023 Dhandha et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding author: Maulik M Dhandha, MD, Woodland Clinic, 632 W Gibson Road, Woodland, CA. E-mail: maulikdhandha@gmail.com Case Presentation A 71-year-old Caucasian male with a past medical history of heart transplant approximately 18 months ago, on tac- rolimus and prednisone presented with chief complaints of redness on the face and hair loss on the eyebrows and mustaches. On examination, he had small spicules overlying scaly erythematous plaques on scalp, eyebrows, chin, upper cutaneous lip and nose (Figure 1). Skin biopsy showed di- lated and distorted follicles with absent hair shaft and ex- pansion of the matrix from the inner root sheath and outer root sheath with dense keratohyalin granules (Figure 2), which are concerning for trichodysplasia spinulosa (TS). Figure 1. Small spicules overlying thin erythematous plaque on the right ala. Figure 2. Histopathology showing dilated and distorted follicles with absent hair shaft and expansion of the matrix from the inner root sheath and outer root sheath with dense keratohyalin granules. 2 Image Letter | Dermatol Pract Concept. 2023;13(3):e2023166 The patient was given an oral valganciclovir low dose of 450 mg daily. At follow up in 4 weeks, the erythema and spicules were significantly decreased. He continued the regimen for another 4 weeks and only had minimal erythema and spicules re- maining. Given his history of chronic kidney disease, val- ganciclovir was stopped with caveat to restart it for short duration as needed. Teaching Point TS is a rare dermatological condition which was first re- ported in the year 1995, and named later in the year 1999. TS is often known as an emerging infectious disease. However, the cases of TS may rise due to the increase in the number of patients on immunosuppressive drug regi- mens [1]. Differential diagnosis for TS includes trichosta- sis spinulosa, follicular hyperkeratotic spicules associated with multiple myeloma, lichen spinulosus, spiky follicular mycosis fungoides, disseminated spiked hyperkeratosis, ulerythema ophryogenes, follicular-based graft versus host disease. Trichodysplasia spinulosa polyomavirus (TSPyV) infects the skin, but in asymptomatic cases the viral DNA is rarely found even if the individuals possess antibodies to the virus. As it is a rare disease, there is no gold standard treatment available till date, but TS has to be timely diagnosed other- wise it may develop into leonine facies [2]. References 1. Curman P, Nasman A, Brauner H. Trichodysplasia spinulosa: A comprehensive review of the disease and its treatment. J Eur Acad Dermatol Venereol. 2021;35(5):1067-1076. DOI: 10.1111/ jdv.17081. PMID: 33559344. PMCID: PMC8247895. 2. Haycox CL, Kim S, Fleckman P, et al. Trichodysplasia spinulosa--a newly described folliculocentric viral infection in an immuno- compromised host. J Investig Dermatol Symp Proc. 1999;4(3): 268-271. DOI: 10.1038/sj.jidsp.5640227. PMID: 10674379.