Abstract

Case presentation: A 10-year-old boy with newly diagnosed B-ALL presented after the completion of his induction chemotherapy with lower extremity muscle weakness, myalgias, and numerous new pink, tender macules on the lower extremities, trunk and forehead. There was clinical suspicion for systemic inflammation based on serology (Ferritin >11000). Biopsy of the lesions showed angioinvasive fungal forms in the subcutis with extension into the deep dermis and surrounding panniculus. Multiple fungal organisms with broad, non-septate hyphae and 90 degree branching were visible within blood vessels. A diagnosis of angioinvasive mucormycosis was made and treatment was initiated. Discussion: Mucormycosis is a rare cutaneous fungal infection that has been reported in up to 17 / 100 000 immunocompromised children with haematological malignancies, most often due to prolonged periods of neutropenia caused by aggressive treatment regimens. Angioinvasion is commonly observed in involved skin and may elicit intravascular thrombosis, causing tissue necrosis. Progression to the disseminated form of the disease is associated with a grim prognosis, with reported mortality rates of 95% . Early diagnosis is important to increase the chance of successful therapeutic intervention and minimize the extent of potential surgical resection. Rapid biopsy and histological identification are critical, as commonly used panfungal antigen tests do not detect the components of Mucorales cell wall, and recovery rate from automated blood culture systems is low. Because of the rarity of the disease, cutaneous may go unrecognized, and a high degree of suspicion should be maintained in neutropenic children undergoing chemotherapy. Here we report the case of a pediatric patient with B-ALL diagnosed with multifocal cutaneous angioinvasive mucormycosis.

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