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JAMA Clinical Challenge | Clinician's Corner

A Violaceous Plaque in an Immunosuppressed Patient FREE

Robert Micheletti, MD; Misha Rosenbach, MD
[+] Author Affiliations

Author Affiliations: Departments of Dermatology and Medicine, University of Pennsylvania, Philadelphia.


JAMA Clinical Challenge Section Editor: Huan J. Chang, MD, Contributing Editor. We encourage authors to submit papers for consideration as a JAMA Clinical Challenge. Please contact Dr Chang at tina.chang@jama-archives.org

More Author Information
JAMA. 2012;307(24):2635-2636. doi:10.1001/jama.2012.4302.
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Published online

A 56-year-old man with acute myelogenous leukemia develops a violaceous plaque on his anterior neck that expands rapidly over the course of one day. The patient was hospitalized a month earlier for salvage chemotherapy with clofarabine. His course has been complicated by prolonged neutropenia and fever of unknown origin, for which he is receiving meropenem, vancomycin, and voriconazole. Physical examination reveals a necrotic-appearing, nonblanching, violaceous plaque on his anterior neck with surrounding erythema (Figure 1). On close inspection, 2 similar violaceous papules are discovered on his tongue and scalp. The patient is febrile but otherwise asymptomatic, with recent negative blood cultures.

Place holder to copy figure label and caption
Figure 1. Nonblanching and necrotic-appearing violaceous plaque on the patient's anterior neck.
Graphic Jump Location

  • A. Draw repeat blood cultures

  • B. Order a computed tomography scan of the head and neck

  • C. Perform a skin biopsy for frozen section processing

  • D. Perform a skin biopsy for routine permanent section processing

Disseminated angioinvasive fungal infection

C. Perform a skin biopsy for frozen section processing

The key feature of this patient's physical examination is the nonblanching, violaceous, necrotic appearance of the plaque on his neck, which suggests vascular compromise in the dermis and devitalization of the overlying tissue. Given the rapidity of onset and the clinical history of prolonged febrile neutropenia, this lesion is worrisome for invasive infection and constitutes a medical emergency. Immediate diagnosis is required to guide management and reduce mortality.1

Angioinvasive fungal infection is a devastating complication of neutropenia, hematologic malignancy, or other profound or prolonged immunosuppression. Responsible organisms include those of the genera Aspergillus, Fusarium, Scedosporium, Mucor, and Rhizopus. Primary cutaneous infection may rarely occur following inoculation injury, such as at the site of an intravenous cannula. Other cutaneous lesions may result from direct extension of underlying infection or via hematogenous dissemination from the lungs or sinuses, in which case more than one lesion may be present.

The importance of a thorough physical examination should be emphasized. Lesions may be hidden under arm boards or tape, at intravenous line sites, or in anatomic areas not readily seen, including the genitals, mucosa, and scalp. Discovery of more than one lesion, as in this case, suggests dissemination, a distinction that changes management and prognosis. A complete skin examination is thus a vital part of the workup of any patient with neutropenia and fever. Skin lesions of angioinvasive fungal infection are typically violaceous papules or plaques with a tendency toward central necrosis resembling a “bull’s-eye infarct.”2 The differential diagnosis of such lesions includes other infectious or noninfectious processes that lead to vascular compromise and skin necrosis, such as ecthyma gangrenosum due to pseudomonal bacteremia, vasculitis, or vasculopathy.

Prompt diagnosis is essential to proper management. Histopathology showing tissue invasion by hyphae is definitive evidence of infection. If available, frozen section processing is preferred because results can be viewed in as little as 20 minutes. Permanent section processing yields higher-quality images and is a reasonable alternative, provided results can be obtained in a timely fashion. “Rush” specimens can be processed in as few as 6 hours but may take as long as 3 days depending on when the specimen is submitted. Institutional variability exists with respect to pathology services, particularly after hours; frozen section processing is widely available, and most hospitals have on-call pathology staff to support the technique.

Isolated primary cutaneous lesions should be treated aggressively. Surgical debridement of a solitary lesion affords the best chance of cure. Systemic antifungal therapy should be initiated but alone is often insufficient; secondary dissemination may occur if the lesion is not excised. If multiple lesions are present or there is evidence of disseminated disease, systemic antifungals should be administered, but mortality approaches 100% without immunologic recovery. Adjuvant measures such as activated granulocyte infusions and granulocyte colony-stimulating factor may be used in some cases, despite little evidence of benefit.3

Voriconazole is the agent of choice for invasive aspergillosis and is also effective against Fusarium and Scedosporium. Because aspergillosis is the most common cause of angioinvasive fungal infection, voriconazole is frequently used as prophylactic or empirical therapy in neutropenic patients. However, Rhizopus, Mucor, and other zygomycetes are resistant to voriconazole and are typically treated with amphotericin B. Some have suggested that widespread use of voriconazole prophylaxis in susceptible patients may be a risk factor for developing zygomycosis.4,5

In this patient, a biopsy of the neck lesion was submitted for immediate processing by frozen tissue pathology. Numerous thick, ribbon-like, translucent, nonseptate hyphae filled the lumen of a subcuticular vessel with destruction of the vessel wall and invasion of the dermis, findings consistent with angioinvasive fungal infection (Figure 2). Computed tomography of the chest and abdomen revealed new pulmonary infiltrates and renal infarcts. Despite immediate initiation of amphotericin B for probable zygomycosis, the patient died 48 hours later following hemorrhage of an undetected frontal lobe lesion, presumably a focus of disseminated fungal infection.

Place holder to copy figure label and caption
Figure 2. Thick, ribbon-like, translucent, nonseptate hyphae filling a vessel in the subcutis (hematoxylin-eosin, original magnification ×400).
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Corresponding Author: Robert Micheletti, MD, 2 Maloney Bldg, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 (robert.micheletti@uphs.upenn.edu).

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Additional Contributions: We thank the patient's wife for providing permission to share his story.

Chamilos G, Lewis RE, Kontoyiannis DP. Delaying amphotericin B-based frontline therapy significantly increases mortality among patients with hematologic malignancy who have zygomycosis.  Clin Infect Dis. 2008;47(4):503-509
PubMed   |  Link to Article
Rubin AI, Grossman ME. Bull’s-eye cutaneous infarct of zygomycosis: a bedside diagnosis confirmed by touch preparation.  J Am Acad Dermatol. 2004;51(6):996-1001
PubMed   |  Link to Article
Tragiannidis A, Groll AH. Hyperbaric oxygen therapy and other adjunctive treatments for zygomycosis.  Clin Microbiol Infect. 2009;15:(suppl 5)  82-86
PubMed   |  Link to Article
Kontoyiannis DP, Lionakis MS, Lewis RE,  et al.  Zygomycosis in a tertiary-care cancer center in the era of Aspergillus -active antifungal therapy: a case-control observational study of 27 recent cases.  J Infect Dis. 2005;191(8):1350-1360
PubMed   |  Link to Article
Trifilio SM, Bennett CL, Yarnold PR,  et al.  Breakthrough zygomycosis after voriconazole administration among patients with hematologic malignancies who receive hematopoietic stem-cell transplants or intensive chemotherapy.  Bone Marrow Transplant. 2007;39(7):425-429
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure 1. Nonblanching and necrotic-appearing violaceous plaque on the patient's anterior neck.
Graphic Jump Location
Place holder to copy figure label and caption
Figure 2. Thick, ribbon-like, translucent, nonseptate hyphae filling a vessel in the subcutis (hematoxylin-eosin, original magnification ×400).
Graphic Jump Location

Tables

References

Chamilos G, Lewis RE, Kontoyiannis DP. Delaying amphotericin B-based frontline therapy significantly increases mortality among patients with hematologic malignancy who have zygomycosis.  Clin Infect Dis. 2008;47(4):503-509
PubMed   |  Link to Article
Rubin AI, Grossman ME. Bull’s-eye cutaneous infarct of zygomycosis: a bedside diagnosis confirmed by touch preparation.  J Am Acad Dermatol. 2004;51(6):996-1001
PubMed   |  Link to Article
Tragiannidis A, Groll AH. Hyperbaric oxygen therapy and other adjunctive treatments for zygomycosis.  Clin Microbiol Infect. 2009;15:(suppl 5)  82-86
PubMed   |  Link to Article
Kontoyiannis DP, Lionakis MS, Lewis RE,  et al.  Zygomycosis in a tertiary-care cancer center in the era of Aspergillus -active antifungal therapy: a case-control observational study of 27 recent cases.  J Infect Dis. 2005;191(8):1350-1360
PubMed   |  Link to Article
Trifilio SM, Bennett CL, Yarnold PR,  et al.  Breakthrough zygomycosis after voriconazole administration among patients with hematologic malignancies who receive hematopoietic stem-cell transplants or intensive chemotherapy.  Bone Marrow Transplant. 2007;39(7):425-429
PubMed   |  Link to Article
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