|LETTER TO THE EDITOR
|Year : 2015 | Volume
| Issue : 4 | Page : 615-616
Dermatological lesions in acute lymphoblastic leukemia
Department of Microbiology, Kidwai Memorial Institute of Oncology, Bangalore, India
|Date of Web Publication||10-Mar-2016|
B G Sumathi
Department of Microbiology, Kidwai Memorial Institute of Oncology, Bangalore
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sumathi B G. Dermatological lesions in acute lymphoblastic leukemia. Indian J Cancer 2015;52:615-6
A 2-year-old girl presented with moderate fever, non-productive cough, bi-lateral jaw, and cheek swelling; swelling of right side of neck (1 × 1 cm) since 15 days. Clinical examination showed bi-lateral swelling of cervical, axillary, and inguinal lymph nodes. No history of trauma was seen. Platelets: 21,000 cells/mm
3; Total count: 1 lakh/mm; and Ultrasonography Ultrasonogram-hepatosplenomegaly. Bone marrow aspirate: Acute Lymphoblastic Leukemia() L1-L2; Cytogenetics; and Normal karyotype. Pancytopenia and thrombocytopenia persisted throughout. Patient was started on chemotherapy, steroid, antibiotics (I.V. Fortum 500 mg b.d.; I.V. Amikacin 75 mg b.d.), and antifungal T. Forcan 50 mg. Radiotherapy deferred due to age.
Patient developed non-discharging, tender erythematous nodules on the anterior chest wall and lower extremities [Figure 1] and simultaneous non-tender, scaly, macular lesions on the scalp [Figure 2]. A fine-needle aspirate cytology (FNAC) report of the nodule showed necrotic material with mixed inflammatory cells. Potassium hydroxide wet mount of the aspirate showed many septate, branching hyphae [Figure 3]. Fungal culture grew Aspergillusflavus [Figure 4]. A repeat FNAC from a different nodule yielded the same growth. T. Forcan was stopped and I.V. Amphotericin B started following which skin nodules subsided. I.V. Amphotericin B was stopped after 15 days due to systemic toxicity. There were subsequent tender, nodular eruptions, following which T. Voritop 50 mg was started but nodules did not subside. I.V. Amphotericin B was restarted, scalp lesions healed, and size of nodules subsided.
In leukemia patients and stem cell transplant recipients, disseminated infection caused by these angioinvasive opportunistic pathogens is serious and life-threatening, with a mortality rate of 50-70%.
Fungal skin nodules persisted despite 5 months of vigorous oral fluconazole indicating resistance of A.flavus. No adverse effects were reported. The fading scaly macular lesions may be due to the side effect of chemotherapy. Recovery from disseminated fungal infections is unlikely, however, unless the patient's pancytopenia resolves. Voriconazole is one of the newer azole antifungal agents, all of which act by inhibiting the production of ergosterol in the plasma membrane of the fungus, and exhibits activity against many pathogenic molds such as Aspergillus. Studies have shown that topical voriconazole solution combined with systemic antifungal therapy is effective and inhibits systemic invasion of cutaneous aspergillosis and thereby, promote better wound healing. Application of topical voriconazole as monotherapy for cutaneous aspergillomas is not advocated but topical voriconazole solution seems to be a viable adjunctive therapy when combined with systemic antifungal agents for the treatment of cutaneous aspergillosis.
Among immunocompetent hosts, lesions are usually localized (13 of 14 patients) and occur after skin breakdown (trauma or pre-existing onychomycosis).
Since the skin may be the source for disseminated and frequently life-threatening fusarial infections, local debridement should be performed and topical antifungal agents (natamycin or amphotericin B) should be used, prior to commencing immunosuppressive therapies.
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Kristin C, Klein R, Blackwood RA. Topical voriconazole solution for cutaneous Aspergillosis
in a pediatric patient after bone marrow transplant. Pediatrics 2006;118:506-08.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]