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Title : A 68 year-old male w/ fever and whole body skin rash
Date : July 27, 2009
Contributed by

Young Eun Ha M.D., Mi Kyong Joung M.D. Samsung Medical Center

Patient History
Age/Sex 68/male
Chief complaint fever and whole body skin rash
Present illness

Patient was admitted for treatment of relapsed acute erythroid leukemia. On hospital day 2, he received reinduction chemotherapy with mitoxantrone, etoposide and cytarabine. On HD 9, he developed septic shock due to K.pneumoniae sepsis. On HD 10, Chest CT showed dense consolidation in LLL. On HD 17, he developded skin rash whick started from face and then rapidly progressed to trunk and extremities

Past medical history

Subtotal gastrectomy for early gastric cancer 10 years ago

Physical examination

Initial V/S 145/76mmHg - 133/min - 22/min - 38.5'C Chest - Inspiratory crackle on LLL Skin - generalized erythematous papules

Initial laboratory findings

CBC 70>9.7<12K (ANC 0 ) CRP 19.14 AST/ALT/ALP 10/7/46 tobal bilirubin 2.4

Radiologic findings

Lobar consolidations have progressed in both lower lobe and right upper lobe with newly appeared patchy ground glass opacity in right middle lobe

Hospital course

On HD 21, skin biopsy was done for accurate diagnosis. Culture of blood and skin from HD 21 were reported to be growing certain microorganisms.

Figure





** Skin biopsy
     - There are septic fungal emboli in the blood vessel.
     -  PAS & BMS stains revelaled branching septated fungal hyphae.


** Culture
     - blood & sputum culture : identified the fusarium spp.

 
Question - ID Case of the Week ( July 27, 2009 )
 
Correct Answer

Disseminated Fusariosis

 
Review

< Disseminaed Fusariosis>

* Fusarium spp.
   - Opportunistic molds, present in soil and on plants.
   - Disseminated Fusariosis usually occurs in severely immunocompromised patients.
   - Emerging pathogen as the second most frequent mold after aspergilus in patients
      with BMT or hematologic malignancies.
   - Port of entry
      Sinopulmonary route, GI tract, indwelling catheters
      Break of skin

* Risk factors
   - Burns, DM, cancer, AIDS
   - BMT patients are most susceptible to Fusarium infection
   - Steroid Tx is not a risk factor for Fusarium
   - Prologed aplasia & pancytopenia increase the risk
* Skin (60~80%) and Blood (40~50%) are the sites most frequently involoved.

* Treatment
   - Antifungal agents 
       F.solani and F. verticillioides : high dose amphotericin B
       Other Fusarium species, high-dose amphotericin B or voriconazole ;
           perform susceptibility testing
   - Immunotherapy
       Growth factors (G-CSF or GM-CSF) or granulocyte transfusions for neutropenic
       patients ; gamma interferon and/or GM-CSF for patients with adquate neutrophil
       counts
   - Surgery 
       Debride necrotic tissue
   - Catheter management
       Remove central venous catheter if isolated fungemia

 


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