No abstract

No abstract

We report an invasive mucormycosis caused by Actinomucor elegans in a patient with refractory aplastic anemia. The organism was isolated from a necrotic skin lesion on the patient's left arm and demonstrated angioinvasive features on histopathology examination. In contrast to three cases described previously, we describe the first case of A. elegans invasive fungal infection in an immunocompromised patient. This report, along with the three previously reported cases, is convincing evidence that A. elegans is an emerging fungal pathogen capable of causing invasive mucormycosis in humans. CASE REPORTA 58-year-old man was diagnosed with aplastic anemia 9 years prior to this presentation. He was initially treated with highdose cyclophosphamide, but achieved only a partial remission; he remained transfusion dependent for several years. He remained neutropenic (absolute neutrophil count, Ͻ500 cells/mm 3 ) over the last 2 years. Three months prior to this presentation, he was hospitalized with possible fungal pneumonia based on the presence of multiple subcentimeter lung nodules, some of which had central cavitations, on a computed tomography (CT) of his chest. Bronchoalveolar lavage cultures for bacteria, fungi, and acid-fast organisms at the time were negative. He was empirically treated with voriconazole for an unknown duration.Three weeks prior to this presentation, the patient presented to an outside hospital with fever and a necrotic lesion on the dorsal surface of the left forearm. His fever persisted, and the lesion continued to progress despite a 2-week course of oral trimethoprim-sulfamethoxazole and amoxicillin-clavulanate. Subsequently, he presented to the outside hospital with rigors and a temperature of 38.9°C. Treatment with intravenous vancomycin and piperacillin-tazobactam was initiated, and the patient was transferred to the Johns Hopkins Hospital for further evaluation and treatment.On admission, he was afebrile (36.4°C) and had normal vital signs. Physical examination revealed a raised 10-cm by 8-cm erythematous area on the dorsal surface of the left forearm distal to the elbow, with a central, irregular, black eschar measuring approximately 5 cm in diameter. Broad-spectrum antibacterial agents were continued, and treatment with fluconazole (400 mg orally once daily) was started. Seven days later, fluconazole was transitioned to voriconazole (400 mg orally every 12 h), based on the finding of a pleural-based consolidative mass in the posteriormedial right lower lobe, measuring 4.0 by 3.0 by 4.2 cm with surrounding ground glass opacity on a chest CT. Sinus CTs did not demonstrate any evidence of concomitant sinusitis. Magnetic resonance imaging of his left upper extremity demonstrated skin ulceration with extensive edema. Multiple sets of blood cultures were negative for fungi and mycobacteria. The patient underwent surgical debridement of the lesion on his left arm, and tissues were sent for histopathology and microbiology examination. Histopathology revealed invasion of underlying blood vessels and...