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Perforating Papules in a Patient With Acute Myeloid Leukemia

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

A woman in her 50s with relapsed refractory acute myeloid leukemia and a remote history of breast cancer was admitted for treatment of presumed fungal pneumonia based on new pulmonary nodules on imaging and elevated serum β-D-glucan levels. She subsequently developed multiple asymptomatic pink papules on the trunk and extremities. The patient was afebrile and was receiving broad-spectrum antibiotic, antifungal, and antiviral treatment for a prior episode of neutropenic fever. Clinical examination revealed scattered pink papules with a white firm center and dark brown core scattered throughout the chest, abdomen (Figure, A and B), back, groin, and upper and lower extremities. Laboratory workup was significant for leukopenia with neutropenia, anemia, and thrombocytopenia. Creatinine and transaminase levels were within normal limits. Blood cultures were negative. A punch biopsy from the left flank was obtained for hematoxylin-eosin staining, and a punch biopsy from the left leg was sent for tissue and fungal culture. Histopathological analysis was subsequently performed (Figure, C and D).

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A. Disseminated candidiasis with transepidermal elimination

The analysis of the skin biopsy specimen revealed a large cluster of fungal organisms in the upper dermis extruding through a cuplike invagination of the epidermis into the stratum corneum (Figure, C and D). Periodic acid–Schiff (PAS) staining highlighted these fungal elements. Wound and fungal cultures subsequently grew Candida albicans. Histologic and laboratory findings supported a diagnosis of disseminated cutaneous candidiasis with transepidermal elimination, correlating clinically with the central core seen on examination. Ophthalmologic evaluation revealed chorioretinitis secondary to Candida infection, and otolaryngology assessment revealed thrush in the oropharynx. Blood cultures, however, remained negative. The patient’s antifungal regimen included amphotericin B and micafungin. The patient was transferred to the intensive care unit for septic shock 2 weeks after presentation and died shortly thereafter.

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Article Information

Corresponding Author: Dana Malajian, MD, Department of Dermatology, Columbia University Medical Center, 161 Ft Washington Ave, 12th Floor, New York, NY 10032 (dmm2201@cumc.columbia.edu).

Published Online: May 15, 2019. doi:10.1001/jamadermatol.2019.0827

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient’s next of kin for granting permission to publish this information. We also would like to acknowledge Paul Schneiderman, MD, for his guidance and clinical photographs. He received no compensation for his contributions.

References
1.
Kashem  SW, Kaplan  DH.  Skin immunity to Candida albicans.  Trends Immunol. 2016;37(7):440-450. doi:10.1016/j.it.2016.04.007PubMedGoogle ScholarCrossref
2.
Perlroth  J, Choi  B, Spellberg  B.  Nosocomial fungal infections: epidemiology, diagnosis, and treatment.  Med Mycol. 2007;45(4):321-346. doi:10.1080/13693780701218689PubMedGoogle ScholarCrossref
3.
Kami  M, Machida  U, Okuzumi  K,  et al.  Effect of fluconazole prophylaxis on fungal blood cultures: an autopsy-based study involving 720 patients with haematological malignancy.  Br J Haematol. 2002;117(1):40-46. doi:10.1046/j.1365-2141.2002.03414.xPubMedGoogle ScholarCrossref
4.
Berenguer  J, Buck  M, Witebsky  F, Stock  F, Pizzo  PA, Walsh  TJ.  Lysis-centrifugation blood cultures in the detection of tissue-proven invasive candidiasis: disseminated versus single-organ infection.  Diagn Microbiol Infect Dis. 1993;17(2):103-109. doi:10.1016/0732-8893(93)90020-8PubMedGoogle ScholarCrossref
5.
Guarana  M, Nucci  M.  Acute disseminated candidiasis with skin lesions: a systematic review.  Clin Microbiol Infect. 2018;24(3):246-250. doi:10.1016/j.cmi.2017.08.016PubMedGoogle ScholarCrossref
6.
Hope  W, Morton  A, Eisen  DP.  Increase in prevalence of nosocomial non-Candida albicans candidaemia and the association of Candida krusei with fluconazole use.  J Hosp Infect. 2002;50(1):56-65. doi:10.1053/jhin.2001.1131PubMedGoogle ScholarCrossref
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