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JAMA Dermatology Clinicopathological Challenge
September 2017

Gray-Violet Plaque in an Immunocompromised Girl

Author Affiliations
  • 1Department of Dermatology, MedStar Georgetown University-Washington Hospital Center, Washington, DC
  • 2Division of Infectious Diseases, Children’s National Health System, Washington, DC
  • 3Division of Dermatology, Children’s National Health System, Washington, DC
JAMA Dermatol. 2017;153(9):923-924. doi:10.1001/jamadermatol.2017.1131

A 4-year-old girl with newly diagnosed acute lymphocytic leukemia, receiving her initial course of chemotherapy with vincristine, daunorubicin, and methotrexate, developed a painful lesion on her left triceps. The tender area was beneath an adhesive bandage placed where she had received DTaP (diphtheria-tetanus-pertussis) and polio vaccinations 3 weeks earlier. Otherwise, she appeared remarkably well, and her vital signs were normal. Removing the bandage revealed a tender indurated gray-violet plaque (Figure, A). White blood cell and neutrophil counts were low at 0.4 K/μL (normal range, 4.86-13.18 K/μL) and 0.18 K/μL (normal range, 1.60-8.29 K/μL), respectively. Blood culture findings were negative. Punch biopsy specimens were obtained for histopathologic analysis (Figure, B) and fungal culture (Figure, C).