Cutaneous Diagnosis of Systemic Disseminated Fusarium Infection in a Pediatric Patient with Leukemia during Hematopoietic Stem Cell Transplantation

Tony S and Mevada R

Published on: 2024-01-14

Abstract

Background: Skin involvement in fusariosis can present as rapidly progressive disseminated lesions.

Case Presentation: We report a 12-year old boy with leukemia with fever on day+31 post-hematopoietic stem-cell transplant. Despite antibiotics, fever continued with emergence of tender scattered papules over back, breakage in skin integrity in interdigital space (right 3rd-4th toes) within next week. Amphotericin-B (3mg/kg) was started in view of suspected fungal infection.

On day+39, patient was started on reconditioning-protocol for second transplant as he failed the primary transplant. Over next 3-4 days, generalized skin lesions appeared in different stages of evolution. Despite high inflammatory markers, blood cultures remained negative.

Skin biopsy performed a week after onset of lesions revealed septate hyphae. Skin culture revealed heavy growth of fusarium with species identification (Fusarium keratoplasticum-sensitive to Amphotercin-B). CT scan revealed focal abnormalities namely thyroid, pulmonary, splenic and renal hypodense lesions favoring diagnosis of disseminated fusarium infection. Fever and skin lesions showed slow resolution over next few weeks. Clinical course was complicated by graft-versus-host disease of gut/skin, cytomegalovirus viremia & adenoviremia; with recurrent episodes of soft tissue swellings at different sites suggesting frequent showering of septic emboli by underlying invasive fungal infection; necessitating continuation of Amphotericin-B (5 mg/kg). Patient succumbed to the disease 13 months post-transplant.

Conclusion: Disseminated fusariosis should be considered as a possible differential in the diagnosis of immune compromised patients with fever; and the appearance of cutaneous lesions should warrant a skin biopsy/culture, as skin might be the only diagnostic source. Prognosis is poor with death without antifungal therapy.