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April 2010

Painful Necrotic Nodules in an Immunocompromised Patient—Diagnosis

Author Affiliations


Arch Dermatol. 2010;146(4):439-444. doi:10.1001/archdermatol.2010.39-b

Histopathologic analysis of the biopsy specimen revealed a full-thickness epidermal and superficial dermal necrosis. High-power magnification revealed numerous angioinvasive fungal forms that were septate hyphae with 45° branching. Culture of the biopsy demonstrated Fusarium organisms. The laboratory findings showed a white blood cell count of 100μL (reference range, 45000/μL-10 000/μL), with a neutrophil count of 0/μL (reference range, 1300-7000 cells/μL) and platelet count of 12 × 103/μL (reference range, 150-400 × 103/ × L). (To convert white blood cells and neutrophils to ×109/L, multiply by 0.001; to convert platelets to ×109/L, multiply by 1.0.) The patient's hospital course was complicated by multiple systemic infections including herpes simplex virus encephalitis, enterococcal bacteremia, and candidemia. Broad spectrum treatment was begun with voriconazole, amphotericin B, cefepime, linezolid, metronidazole, and acyclovir. However, after 2 weeks of intense treatment, she remained pancytopenic with a decreased level of consciousness, tachypnea, anasarca, and renal failure. The patient died shortly after the family elected for comfort care.

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