Abstract:

Toxic erythema of chemotherapy (TEC) is an adverse reaction to chemotherapy that encompasses a spectrum of clinical and histopathologic findings. Herein, we describe a patient with acute myeloid leukemia presenting with an acute onset lesion on the lower leg which was found to show both TEC and angioinvasive fungal organisms. The patient is a 27-year-old male with a history of chronic graft versus host disease status post allogenic stem cell transplant who underwent hypomethylating agent chemotherapy for relapse. Approximately nineteen days after his last dose of decitabine and cedazuridine, the patient presented with an acutely worsening 5 cm erythematous-violaceous, minimally indurated plaque on his right ankle. Histopathological analysis revealed epidermal necrosis with ulceration, epidermal dysmaturation and eccrine squamous syringometaplasia consistent with TEC. Angioinvasive fungus was also identified on H&E and confirmed with GMS stain. The patient is currently undergoing treatment with micafungin, liposomal amphotericin B, and posaconazole with slight improvement of his rash; surgical management is deferred due to concern for pulmonary and disseminated fungal infection. Because of its varied clinical presentation and occurrence in immunocompromised individuals, the differential diagnosis of TEC includes infectious exanthema and GVHD. Both GVHD and TEC are classically associated with a vacuolar interface dermatitis. The findings of eccrine squamous syringometaplasia and epidermal dysmaturation are useful distinguishing histopathologic features when present. Additionally, biopsies containing fungal organisms in immunocompromised patients may not show a significant inflammatory response. The co-occurrence of angioinvasive fungal infection and TEC emphasizes the importance of careful inspection for second diagnoses even after rendering a relatively rare and interesting background diagnosis.

Financial Disclosure:
No current or relevant financial relationships exist.

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Ashleigh Tomkovich, MD