Case Presentation: A 67-year-old male with acute myelogenous leukemia (AML) with chronic neutropenia presented with acute onset of fevers accompanied by rapidly progressing violaceous lesions with a central eschar within a period of 48-72 hours. The maculopapular lesions were initially observed to be small, petechial lesions which progressed in size involving the left forearm, posterior nape of neck, left posterior calf, right posterior shoulder and left lateral neck. The patient denied any other constitutional symptoms other than fatigue, diaphoresis, and chills.
Past medical history was significant for diabetes, pancytopenia, tuberculosis exposure with negative tuberculosis skin test, and subcentimeter pulmonary nodules presumed to be remnants of prior histoplasmosis exposure.
Initial evaluation of the patient revealed multiple non-pruritic, non-blanchable, tender, violaceous lesions with central eschar with the largest lesion involving the left posterior calf measuring approximately 6 cm in greatest diameter and onychomycosis of the left big toe. No oromucosal or ocular lesions were noted. Initial temperature was 103.4 F¢ª. Laboratory data was remarkable for pancytopenia with an absolute neutrophil count of 280 k/μL. CT Thorax revealed a new, small left upper lobe nodule. Histoplasma galactomannan antigen was negative. In the setting of neutropenic fever, empiric antibiotic therapy was initiated with IV cefepime, amphotericin, posaconazole, and acyclovir. Shave biopsy of left forearm was positive for angioinvasive hyalohyphomycosis. Fungal blood cultures grew out 1+ Fusarium species within 48 hours of collection. Blood and urine cultures remained negative. Following initiation of anti-fungal therapy, the lesions gradually regressed. Posaconazole 300mg daily was continued for 3 months duration at the time of discharge.
Discussion: Cutaneous manifestations that can arise in the setting of AML with prolonged neutropenia are leukemia cutis, vasculitis, ecthyma gangrenosum associated with pseudomonas bacteremia, pyoderma gangrenosum, and acute febrile neutrophilic dermatosis. Disseminated fusariosis has increasingly emerged as an etiology of such progressive cutaneous lesions in patients with hematologic malignancies, especially in acute leukemias. Untreated disseminated fusariosis carries a 60 to 80% mortality rate. In 70% of the cases, patients develop cutaneous lesions as the initial presenting sign. Definitive diagnosis is confirmed by histopathology and tissue biopsy with cultures. Optimal therapy for disseminated fusariosis is a combination of antifungal therapy with amphotericin and posaconazole.
Conclusions: In immunocompromised patients, this case serves to raise awareness amongst hospitalists of the potential of disseminated fusariosis presenting as progressive cutaneous lesions. If detected early by practitioners, mortality rates can be significantly reduced with initiation of combination antifungal therapy.
To cite this abstract:Eaton K, Holmstrom B. “Deadly” Rash of Fusariosis. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 512. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/deadly-rash-of-fusariosis/. Accessed April 2, 2020.