Background Cellulitis is an infection most commonly caused by bacteria and successfully treated with antibiotics. However, certain patient populations, especially the immunocompromised, are at risk for fungal cellulitis, which can be misidentified as bacterial cellulitis and contribute to significant morbidity and mortality. Case presentations We describe three cases of opportunistic fungal cellulitis in immunosuppressed patients that were initially mistaken for bacterial infections refractory to antibiotic therapy. However, atypical features of cellulitis ultimately prompted further diagnostics to identify fungal cellulitis and allow initiation of appropriate antifungals. We discuss: (1) a 52-year-old male immunosuppressed hematopoietic cell transplant recipient with Fusarium solani cellulitis on his right lower extremity that was treated with amphotericin B and voriconazole with full resolution of the cellulitis; (2) a 70-year-old male lung transplant recipient with Fusarium solani cellulitis on his left lower extremity that ultimately progressed despite antifungals; and (3) a 68-year-old male with a history of kidney transplantation with suspected Purpureocillium lilacinum cellulitis on his left lower extremity ultimately treated with posaconazole with resolution of the skin lesions. Conclusions Fusarium solani and Purpureocillium lilacinum are important pathogens causing opportunistic fungal cellulitis. These cases remind providers to be vigilant for fungal cellulitis when skin and soft tissue infection does not adequately respond to antibiotics and atypical features of cellulitis are present.
A 72-year-old man with type 2 diabetes mellitus, hypertension, osteoarthritis, and pancreatic insufficiency on enzyme replacement presented to primary care with a painful subcutaneous elbow nodule. Oral antibiotics were prescribed for presumed cellulitis and then indomethacin. However, new nodules developed, and he was admitted. Punch biopsy showed necrotizing panniculitis; 10 days after admission, he was transferred to a tertiary care center for dermatology/rheumatology consultation.Examination showed multiple exquisitely tender, erythematous, subcutaneous nodules on the extremities with several overlying joints and some draining serous fluid (Fig. 1). There were significant swelling, erythema, and warmth of bilateral ankles, right second proximal interphalangeal (PIP) joint, and right elbow with suspected synovitis. Patient also endorsed unintentional 20lb weight loss over 6 months.Notable abnormal laboratory findings included erythrocyte sedimentation rate, 56 mm/h (reference range, 0-20 mm/h); C-reactive protein, 25.1 mg/L (reference, <3.0 m/L); uric acid, 10.7 mg/dL (reference range, 3.4-7.0 mg/dL); α1 antitrypsin, 278 μmol/L (reference range, 20-50 μmol/L); creatinine, 1.2 mg/dL (reference range, 0.8-1.2 mg/dL); and angiotensin-converting enzyme, <5 U/L (reference range, 23-57 U/L). Bac terial cultures, fungal cultures, and serological testing for HIV, tuberculosis, Coxiella burnetii, syphilis, and hepatitis B/C viruses were negative. Furthermore, autoantibodies, chest radiograph, and echocardiogram were normal.Repeat biopsy was consistent with pancreatic panniculitis (Fig. 2). Ultrasound evaluation of PIPs showed flexor tendon hypoechogenicity, fibrillary pattern loss, marked peritendinous hyperemia, and effusions (Fig. 3). There were no corresponding joint effusions or synovial changes. Ankle ultrasound findings were similar.Despite no abdominal pain or any pancreatitis history, lipase was 600 U/L (reference range, 0-160 U/L), and amylase was 1166 U/L (reference range, 23-85 U/L). Computed tomography showed pancreatic fatty atrophy with no focal lesions and multiple portal vein nonocclusive thrombi. Esophagogastroduodenoscopy revealed a 1.7 Â 2.8-cm ill-defined, hypoechoic region in the pancreatic head. Fine-needle aspiration showed adenocarcinoma in association with a mucinous neoplasm. CA19-9 antigen was 936,000 U/L (reference, <35,000 U/L). Positron emission tomography/computed tomography showed mild FDG uptake in pancreatic head and in extremities with panniculitis. Oncology/ general surgery recommended neoadjuvant chemotherapy followed by Whipple procedure. The patient elected to pursue outpatient chemotherapy near home and was discharged to a nursing facility.
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