We describe a case of disseminated Beauveria bassiana infection in a patient with acute lymphoblastic leukemia. Her infection was successfully treated with amphotericin B and itraconazole. B. bassiana is rarely reported as a human pathogen. It is commonly found in soil and because of its pathogenicity to many insect species is incorporated into several pesticides. CASE REPORTA 44-year-old Caucasian woman was diagnosed with acute lymphoblastic leukemia. She had a history of recurrent sinusitis but was otherwise well. She lived in a rural area of the South Island of New Zealand and owned a garden center.At presentation she had a neutrophil count of 0.36 ϫ 10 9 / liter but was clinically well with no signs of infection and commenced treatment with prophylactic ciprofloxacin and fluconazole. She was nursed in a positive-pressure single room and given a low-bacteria diet. At day 1 of induction chemotherapy (United Kingdom Acute Lymphoblastic Leukemia 12 protocol), ciprofloxacin and fluconazole were stopped, and co-trimoxazole and nystatin were started. At day 15 of treatment the patient became febrile, and Streptococcus viridans was isolated from blood cultures. She was treated with piperacillin and gentamicin, and her temperature stabilized. She remained neutropenic, and at day 20, small (Ͻ1-cm) purple macular "cigarette burn " lesions were noted on her left upper arm (Fig. 1A). An aspirate sent for bacteriology and skin scrapings sent for fungal culture yielded no microorganisms. Four days after the skin lesions developed, she complained of symptoms of sinusitis, headache, and facial pain and had percussion tenderness over her maxillary sinuses. Paranasal sinus disease was not identified by computed tomography scanning, and in view of her persisting neutropenia further invasive investigations were not performed. Serum transaminases were elevated on day 21, but an abdominal ultrasound scan was normal.Fluconazole was restarted on day 28, and an excision biopsy of one of the skin lesions was performed the next day. Histopathological examination of the biopsy specimen revealed sharply demarcated areas of necrosis with lack of cellular reaction at the interface. The necrotic tissue was heavily permeated by fungal hyphae, which also invaded the local blood vessels (Fig. 2). Cultures of the tissue biopsy sample on blood agar and Sabouraud glucose agar plates at 30°C produced a pure growth of a white mould identified preliminarily as a Beauveria sp. No recovery of the mould was obtained on plates incubated at 35°C. The susceptibility of the isolate was assessed using Sensititre Yeast One susceptibility plates (Trek Diagnostic Systems, West Sussex, England). Testing was performed at 30°C, and the MIC was read after 72 h of incubation. The susceptibility results were as follows: the amphotericin B MIC was 2.0 mg/liter, the itraconazole MIC was 0.06 mg/liter, the fluconazole MIC was 8.0 mg/liter, the ketoconazole MIC was 0.125 mg/liter, and the 5-flucytosine MIC was Ͼ64 mg/liter.Prednisone was stopped on day 37 of phase 1 in...

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