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On day 15 of induction therapy with intravenous cytarabine, vincristine sulfate, dexamethasone, pegaspargase, and intrathecal methotrexate, a 3-year-old girl with B-cell acute lymphoblastic leukemia presented to the oncology department with an asymptomatic skin lesion. No known skin trauma occurred. The patient was afebrile, and vital signs were stable. On examination, a 4.0 × 2.0-cm, oval-shaped violaceous to black plaque with a central hemorrhagic bulla and surrounding hyperemia was noted on the left lower back (Figure 1). A complete blood cell count revealed a white blood cell count of 1800/μL (to convert to ×109/L, multiply by 0.001), with 2% neutrophils (absolute neutrophil count, 36/μL [to convert to ×109/L, multiply by 0.001]), hemoglobin level of 8.2 g/dL (to convert to grams per liter, multiply by 10), and platelet count of 10 × 103/μL (to convert to ×109/L, multiply by 1). Her blood glucose level was 326 mg/dL (to convert to millimoles per liter, multiply by 0.0555). The patient was administered broad-spectrum antibiotics empirically, and a dermatologist was consulted. Two punch biopsy specimens from the lower back plaque were obtained and sent for histologic analysis and tissue culture (bacteria, atypical mycobacteria, and fungus).
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Histologic sections from the lesional skin revealed nonseptate broad-branching fungal hyphae within and occluding dermal vessels, confirming angioinvasive mucormycosis (Figure 2A and B). Cutaneous and sinus tissue cultures similarly yielded Mucorales species, reflecting a disseminated angioinvasive mucormycosis infection. Imaging results were negative for pulmonary invasion. Combination antifungal therapy with intravenous liposomal amphotericin B, posaconazole, and micafungin was initiated, and excision was undertaken. Induction therapy was reinstated 24 days later.
Mucormycosis comprises fungal infections of the class Zygomycota and the order Mucorales. Rhizopus species represent the most frequently isolated causative organism that microscopically appears as nonseptate, broad-branching hyphae. These organisms are omnipresent in nature and are rarely pathogenic in immunocompetent patients.
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Corresponding Author: Paul R. Massey, MD, Division of Dermatology, Dell Medical School, University of Texas at Austin, 1400 N I-35, Ste C2.470, Austin, TX 78701 (firstname.lastname@example.org).
Published Online: July 19, 2018. doi:10.1001/jamaoncol.2018.2086
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient’s parent for granting permission to publish this information.
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