Successful outcome of mucormycosis in two children on induction therapy for acute lymphoblastic leukemia
A 10-year-old male was on induction chemotherapy (BFMBerlin-Frankfurt-Münster-95 protocol) for moderate risk T cell ALL. On day 11 of induction, he was observed to have a scabbed wound (2 cm × 2 cm) on the lateral aspect of his left forearm. There was a history of trauma 4 days ago. As the wound was in close proximity to the central line, parenteral antibiotics were started immediately. Antibiotics were switched from cefoperazone-sulbactam to meropenem and amikacin after 48 hour of non-response. Although absolute neutrophil count (ANC) = 60/mm3, child remained afebrile, non-toxic, capillary refill was brisk and radial pulsations were well-felt. Repeated blood and wound swab cultures were sterile. The lesion progressed and conventional amphotericin-B (CAB) was started on D18 of induction, after taking a skin biopsy for culture and histology. Skin scrapping showed growth of non-septate hypha, branching at right angles, diagnostic of mucormycosis. CAB was continued for 12 weeks, along with radical serial debridement of the necrotic wound. Computed tomography (CT) chest was normal. Induction chemotherapy was continued with prednisolone, vincristine, and L-asparaginase, however, only first dose of daunorubicin could be administered. Skin grafting by rotation flap was carried out to cover the exposed ulna proximal to the styloid process []. He achieved complete remission (CR) and subsequent cycles of chemotherapy were administered as per the protocol. He completed his treatment and is off therapy for the past 7 months.