Medium-power microscopy showed acral skin with a hemorrhagic crust and marked epidermal and dermal necrosis. No obvious vascular thrombosis was present. Closer inspection revealed numerous septate hyphae with acute angle branching, features that were accentuated with the periodic acid–Schiff and methenamine silver stains. Cultures of the bulla fluid, resected bowel, sputum, and bronchial lavage yielded Aspergillus flavus. Blood cultures remained negative for organisms throughout the patient’s hospital course. Despite aggressive treatment with amphotericin B and fluconazole, the patient’s condition deteriorated rapidly, and she died 3 days later.
Necrotic Ulcer on the Thumb of a Teenager With Leukemia—Diagnosis. Arch Dermatol. 2005;141(5):633-638. doi:10.1001/archderm.141.5.633-h