Successful outcome of mucormycosis in two children on induction therapy for acute lymphoblastic leukemia
A 4-year-old male diagnosed with standard risk pre-cursor B ALL was hospitalized on day 4 of induction chemotherapy for fever and cellulitis on the dorsum of the right hand, at venous cannula site. As he was neutropenic (ANC = 100/mm3) broad spectrum antibiotics were administered to cover both gram positive and gram negative bacteria. The wound progressed to an abscess and pus culture grew antibiotic sensitive Pseudomonas aeruginosa. Despite the specific therapy (cefoperazone-sulbactam, amikacin), the patient developed a necrotic area at the tip of the little finger of the same hand, suggestive of ecthyma gangrenosum []. He subsequently developed pain and swelling over the right shoulder and as he had a central line on the same arm (8 cm from the wound), the line was removed despite normal coagulation profile and Doppler study. Shoulder pain resolved within 24 h of removing the line. As child remained afebrile, non-toxic and hemodynamically stable, induction chemotherapy was continued with some modification (no daunorubicin after D8). On D19, he developed another black skin lesion on the lateral aspect of left leg [] and skin scrapping from the lesion grew Streptococci on initial culture. However, due to progression, biopsy from the leg lesion was done and liposomal amphotericin B (LAB) was started. Histopathological examination showed broad ribbon-like non-septate hypha branching at the right angle, suggestive of mucormycosis. The fungal culture showed fluffy, grey, cotton candy-like growth that was identified as Rhizomucor pussilus []. CT scan of the chest revealed multiple, bilateral pulmonary lesions with right pleural effusion (at this time patient also had a cough and tachypnea). Successful control of mucormycosis was achieved by serial surgical debridement of both cutaneous lesions, wedge resection of two large lung lesions along with LAB and posaconazole (12 weeks). After completion of induction patient achieved CR and subsequent chemotherapy was administered as per protocol. He has completed his treatment and is off therapy for 4 months. The clinical characteristics of both cases are summarized in .