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  Table of Contents  
LETTER TO THE EDITOR
Year : 2015  |  Volume : 52  |  Issue : 4  |  Page : 615-616
 

Dermatological lesions in acute lymphoblastic leukemia


Department of Microbiology, Kidwai Memorial Institute of Oncology, Bangalore, India

Date of Web Publication10-Mar-2016

Correspondence Address:
B G Sumathi
Department of Microbiology, Kidwai Memorial Institute of Oncology, Bangalore
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.178387

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How to cite this article:
Sumathi B G. Dermatological lesions in acute lymphoblastic leukemia. Indian J Cancer 2015;52:615-6

How to cite this URL:
Sumathi B G. Dermatological lesions in acute lymphoblastic leukemia. Indian J Cancer [serial online] 2015 [cited 2019 Dec 14];52:615-6. Available from: http://www.indianjcancer.com/text.asp?2015/52/4/615/178387


Sir,

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.
Figure 1: Skin nodule on right lateral aspect of thigh

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Figure 2: Macular lesion on scalp

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Figure 3: Many septate hyphae seen on wet mount of fine needle aspirate

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Figure 4: Aspergillus flavus culture

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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%.[1]

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.[2] 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.[3] 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).[1]

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.[1]

 
  References Top

1.
Nucci M, Anaissie E. Fusarium infections in immunocompromised patients. Clin Microbiol Rev 2007;20:695-704.  Back to cited text no. 1
    
2.
Mays SR, Bogle MA, Bodey GP. Cutaneous fungal infections in the oncology patient: Recognition and management. Am J Clin Dermatol 2006;7:31-43.  Back to cited text no. 2
    
3.
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.  Back to cited text no. 3
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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