A New Dark Skin Lesion in a 3-Year-Old Undergoing Acute Lymphoblastic Leukemia Induction Therapy | Dermatology | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

A New Dark Skin Lesion in a 3-Year-Old Undergoing Induction Therapy for Acute Lymphoblastic Leukemia

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

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).

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

D. Mucormycosis

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.

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

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 (prmassey@ascension.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.

References
1.
Kauffman  CA, Malani  AN.  Zygomycosis.  Curr Infect Dis Rep. 2007;9(6):435-440.PubMedGoogle ScholarCrossref
2.
Greenberg  RN, Scott  LJ, Vaughn  HH, Ribes  JA.  Zygomycosis (mucormycosis).  Curr Opin Infect Dis. 2004;17(6):517-525.PubMedGoogle ScholarCrossref
3.
Yohai  RA, Bullock  JD, Aziz  AA, Markert  RJ.  Survival factors in rhino-orbital-cerebral mucormycosis.  Surv Ophthalmol. 1994;39(1):3-22.PubMedGoogle ScholarCrossref
4.
Roden  MM, Zaoutis  TE, Buchanan  WL,  et al.  Epidemiology and outcome of zygomycosis.  Clin Infect Dis. 2005;41(5):634-653.PubMedGoogle ScholarCrossref
5.
Zaoutis  TE, Roilides  E, Chiou  CC,  et al.  Zygomycosis in children.  Pediatr Infect Dis J. 2007;26(8):723-727.PubMedGoogle ScholarCrossref
6.
Pana  ZD, Seidel  D, Skiada  A,  et al; Collaborators of Zygomyco.net and/or FungiScope™ Registries.  Invasive mucormycosis in children.  BMC Infect Dis. 2016;16(1):667.PubMedGoogle ScholarCrossref
7.
Adam  RD, Hunter  G, DiTomasso  J, Comerci  G  Jr.  Mucormycosis.  Clin Infect Dis. 1994;19(1):67-76.PubMedGoogle ScholarCrossref
8.
Roilides  E, Zaoutis  TE, Walsh  TJ.  Invasive zygomycosis in neonates and children.  Clin Microbiol Infect. 2009;15(suppl 5):50-54.PubMedGoogle ScholarCrossref
9.
Science  M, Robinson  PD, MacDonald  T, Rassekh  SR, Dupuis  LL, Sung  L.  Guideline for primary antifungal prophylaxis for pediatric patients with cancer or hematopoietic stem cell transplant recipients.  Pediatr Blood Cancer. 2014;61(3):393-400.PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close