A 63-year-old man presented with 2 months of right upper extremity (RUE) redness and swelling 17 months after deceased donor renal transplant. He underwent hemodialysis for hypertension-induced renal failure for 3 years pretransplant via a left upper extremity radiocephalic arteriovenous fistula. Although not sensitized pretransplant, he received thymoglobulin induction for anticipated delayed graft function. Allograft function did not recover. He remained on dialysis and relisted for transplantation, while maintained on tacrolimus, mycophenolic acid, and prednisone. Two months before presentation, he noted gradual swelling involving his right hand second and fourth digits. This progressed to involve the right palm, wrist, and elbow with associated pain and erythema. He denied RUE trauma, fever, or systemic symptoms. He denied exposures to animals, gardening, caves, freshwater bodies, or construction sites. He lived in North Carolina with no travel outside the region. Examination revealed erythematous, tender, and fluctuant nodules involving the right wrist and palm, second and fourth digit dactylitis (Figure 1), and right olecranon bursitis. RUE joint range of motion was intact. His examination was otherwise unremarkable. Laboratory data: white blood cell count 1300 cells/mm3 (neutrophils 1058 cells/mm3, lymphocytes 138 cells/mm3), hemoglobin 7.6 g/dl, platelets 176 000/µl, and normal liver functions. RUE magnetic resonance imaging (MRI) demonstrated full-thickness soft tissue edema with large nodular areas of heterogeneous signal abnormality correlating with his examination, without abscess or osteomyelitis. Hypothenar eminence skin biopsy demonstrated extensive dermal and subcutaneous tissue necrosis (Figure 2). Periodic-acid Schiff stain and cultures from the olecranon bursa fluid aspirate and skin biopsy showed Histoplasma capsulatum. 1How do most transplant recipients acquire histoplasmosis?aEnvironmental fresh water exposurebInhalation of airborne sporescPerson to person transmissiondTransmission through an animal biteeTransmission via the donor allograft2Which study is most likely to reveal an additional site of infection in this case?aBone marrow biopsybEchocardiographycChest computed tomography (CT)dMRI braineMRI spine3Which clinical feature supports tenosynovitis with concomitant deeper soft tissue infection of the wrist and hand?aConcomitant olecranon bursitisbDactylitis with intact joint range of motioncLack of discrete abscess formation on imagingdSubacute progression of clinical findingseSubcutaneous tissue necrosis on skin biopsy4Despite discontinuing immunosuppression and administering liposomal amphotericin B (AMB) for 3 weeks, the patient’s right-hand abnormalities failed to demonstrate significant clinical improvement. What is the best next step in the management of this patient’s infection?aContinue with liposomal AMB to allow more time for a clinical responsebAdd an azole antifungal agent to the treatment regimencAdd empiric antibacterial coverage for possible superinfectiondAdminister high dose steroids to treat immune reconstitution syndromeePerform surgical exploration and debridement