Abstract

While antifungal prophylaxis is effective in high-risk patients with hematologic malignancies, the relative dearth of angioinvasive fungal infections along with rising levels of fungal resistance has diminished support for universal prophylaxis. Here, we present a case of multiple angioinvasive fungal infections in a 65-year-old male with a history of chronic myeloid leukemia admitted for blast crisis. The patient was leuko-reduced with hydroxyurea and initiated on FLAG-IDA with course complicated by febrile neutropenia without initiation of antifungal prophylaxis. The patient developed a pink papule on the chest that rapidly progressed to a necrotic plaque and a violaceous nodule with a central ulcer on the right third toe. Blood cultures were drawn and empiric amphotericin B was initiated. Skin punch biopsy of the chest demonstrated thin-walled, ribbon-like hyphae without visible septa, with predilection for neurovascular bundles. Corresponding skin tissue culture was initially negative, with a subsequently obtained specimen confirming mucormycetes. In contrast, skin punch biopsy of the toe demonstrated narrow septate hyphae within the vasculature with corresponding tissue culture pending. Blood cultures were negative. The patient underwent wide local excision of the chest and right third toe amputation with course ongoing at time of abstract submission. Skin punch biopsies for both tissue culture and histopathology are integral to the workup of angioinvasive fungal infections. This case serves as a vantage point from which to review the various clinicopathologic challenges encountered during this workup: multiple fungal species may be causative in immunocompromised patients, the histologic morphology of angioinvasive fungi may be misleading, and tissue culture may be falsely negative.

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