Levamisole-induced vasculitis is a relatively new entity in people who use cocaine. We describe a 44-year-old woman with a history of cocaine use who presented with a complaint of a painful rash of 2-3 month’s duration on her extremities, cheeks, nose, and earlobes. She had not experienced fever, weight loss, alopecia, dry eyes, oral ulcers, photosensitivity, or arthralgia. Examination revealed tender purpuric eruptions with central necrosis on her nose, cheeks, earlobes, and extremities. Laboratory investigations revealed neutropenia, an elevated erythrocyte sedimentation rate (ESR), presence of lupus anticoagulant, low complement component 3 (C3), and presence of perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA). A urine toxicology screen was positive for cocaine, and gas chromatography–mass spectrometry was positive for levamisole. Skin biopsy showed leukocytoclastic vasculitis and small vessel thrombosis. Necrotic lesions of the nose led to its self-amputation. Large bullae on the lower extremities ruptured, leading to wound infection and extensive necrosis that required multiple surgical debridements. When necrosis progressed despite debridement, bilateral above-knee amputation of the legs was performed. Once new lesions stopped appearing, the patient was discharged home. Two months later, she had a recurrence related to cocaine use. To the best of our knowledge, this is only the second reported case of levamisole-induced vasculitis that required above-knee amputation.

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The majority of invasive mold infections diagnosed in immunocompromised cancer patients include invasive aspergillosis (IA) and mucormycosis. Despite timely and effective therapy, mortality remains considerable. Antifungal agents currently available for the management of these serious infections include triazoles, polyenes, and echinocandins. Until recently, posaconazole has been the only triazole with a broad spectrum of anti-mold activity against both Aspergillus sp. and mucorales. Other clinically available triazoles voriconazole and itraconazole, with poor activity against mucorales, have significant drug interactions in addition to a side effect profile inherent for all triazoles. Polyenes including lipid formulations pose a problem with infusion-related side effects, electrolyte imbalance, and nephrotoxicity. Echinocandins are ineffective against mucorales and are approved as salvage therapy for refractory IA. Given that all available antifungal agents have limitations, there has been an unmet need for a broad-spectrum anti-mold agent with a favorable profile. Following phase III clinical trials that started in 2006, isavuconazole (ISZ) seems to fit this profile. It is the first novel triazole agent recently approved by the United States Food and Drug Administration (FDA) for the treatment of both IA and mucormycosis. This review provides a brief overview of the salient features of ISZ, its favorable profile with regard to spectrum of antifungal activity, pharmacokinetic and pharmacodynamic parameters, drug interactions and tolerability, clinical efficacy, and side effects.

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The incidence of invasive fungal infections in immunocompromised cancer patients has continued to increase over the last few decades. With an increase in the use of broad spectrum antifungal prophylaxis, changes in transplant protocols, novel chemotherapeutic agents as conditioning regimens, use of potent B and T cell immunosuppressive agents to decrease the incidence of graft virus host disease, and an increase in the immunocompromised pool of patients, there has been a noticeable shift in the epidemiology of invasive fungal infections. Empiric therapy targeting frequently reported or expected fungal pathogens may fail because of the emergence of rare pathogens and a change in risk factors in the host. Emergence of rare yeasts and molds, often poses a challenge to clinicians involved in the care of these patients. This article provides a brief overview of rare fungal pathogens that have emerged in cancer patients over the last several years. It is meant to deliver an integrated and strategical approach for the diagnosis and management of these unique infections, from a clinical perspective.

Background The deaths due to coronavirus disease (Covid-19) in Michigan have been disproportionately centered in the city of Detroit. We sought to characterize hospitalized veterans with Covid-19 infection in Detroit, MI and compare them to inpatients previously reported. Methods A retrospective observational study of 79 veterans admitted to a veteran's hospital with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between March 10, through April 6, 2020. Each patient had at least 30 days of follow-up. Results The median age of 79 enrolled patients was 69.0 years (interquartile range, 57.0–75.0 years) and 74 (94%) were men. Twenty-four (30%) had a recent emergency department visit. Respiratory symptoms were present in 67 (85%). Gastrointestinal symptoms were common (49 [62%]), including diarrhea (27 [34%]) and loss of appetite (31 [39%]). Only 30 (38%) patients had fever on admission. Comorbidities included hypertension (73 [92%]), diabetes (48 [61%]), obesity (42 [53%]), chronic obstructive pulmonary disease (30 [38%]), coronary disease (28 [35%]), and obstructive sleep apnea (25 [32%]). Nine patients were admitted to the intensive care unit, and 18 (26%) of 70 required intensive care unit transfer. Twenty-Four (30%) were intubated; of which 3 were extubated and 20 (83%) died. Of the 57 (72%) patients discharged alive, 22 (39%) required supplemental oxygen and 8 (14%) were readmitted within 30 days. Conclusions Detroit veterans were primarily older African American men with more comorbidities than inpatients previously described. Gastrointestinal symptoms were twice as common as fever. Rates of mortality and readmission were higher than those previously reported in populations with shorter follow up.