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On day 14 of neutropenia, an astute ID fellow noted this finding (photo) while examining a patient with fever. Underlying AML and ongoing chemotherapy.

What do you suspect? What work up do you suggest? Details and #MayoIDQ MCQ to follow...
65M acute myeloid leukemia. Rx: CLAG-M. Prophy ACV, posaconazole, Levo, inhaled pentamidine

D14 neutropenia: fever / chills
Exam: onychomycosis, rapidly evolving lesions in arms and torso (photo)

You asked for skin biopsy. Blood culture will grow what fungus?
2/
 Case diagnosis: disseminated fusariosis

Majority got the diagnosis correctly!
Blood culture: Fusarium sp.

Rx: AmBisome / voriconazole
Hope for neutrophil recovery!!!
3/
 #Ecthyma gangrenosum

Mechanism: perivascular invasion of vessels —> ischemic necrosis —> “punched out” ulcer

Classic associations
1. Bacteria: Pseudomonas aeruginosa most common overall; also - S aureus, NTM, etc...
3. Fungi: Fusarium most common

link.springer.com/article/10.100…
4/
 #Onychomycosis is a risk for #Fusarium

Screen for onychomycosis in patients especially if they are anticipated to be neutropenic.

doi.org/10.1111/ijd.12…
5/
 Why not Cryptococcus neoformans in this case?

Posaconazole (patient is receiving this for prophylaxis) has excellent activity against cryptococcus

doi.org/10.1093/jac/48…
6/
 #Posaconazole is active against mycelial infections but breakthroughs have occurred

Breakthrough #fusariosis may occur in patients on posaconazole prophylaxis

#Aspergillus and #Mucor breakthroughs have also occurred

jcm.asm.org/content/49/4/1…
7/
 #Aspergillus does NOT grow in blood cultures ... even in populations at highest risk of invasive aspergillosis

This makes it less likely in this case.

nature.com/articles/17047…
8/
 Rhizopus / Mucor does NOT grow in blood cultures

This makes it less likely in this case.

ncbi.nlm.nih.gov/pmc/articles/P…
9/
 Antifungal Rx of #Fusariosis
Preferred (alone or in combination)
- AmBisome
- Voriconazole

Potential alternatives/limited data:
- Posaconazole
- Isavuconazole

No effect!!!
- Fluconazole
- Itraconazole
10/
 Outcome of #fusarium infection in ICH
#Neutrophil recovery is key!

Strategies:
- G-CSF
- Dexamethasone-stimulated granulocyte transfusions
- Interferon-gamma

Important: neutrophil recovery needed!

doi.org/10.1111/trf.13…
/11
#ClinicalPearls
1. Fusarium common fungal cause of ecthyma gangrenosum
2. Aspergillus / Mucor do NOT grow in blood cultures
3. Onychomycosis - risk for fusariosis
4. Mycelial breakthroughs happen on azole prophylaxis
5. Neutrophil recovery is key to outcome of mycelial infxns
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Related hashtags

#MayoIDQ #Ecthyma #Onychomycosis #fusarium #Posaconazole #Fusariosis #Aspergillus #Mucor #Neutrophil #ClinicalPearls

More from @MayoClinicINFD see all

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Mayo Clinic Infectious Diseases
@MayoClinicINFD
Images of Infectious Diseases

This is the histopath and gram stain of culture of a lymph node biopsy of a person with tender purulent inguinal adenopathy.
Dr. @dwchallener
Dr. @ali_eberly
MCQ #MayoIDQ to follow Image
72M. Crohn’s. 2 pet dogs. 1 pet cat.
2 mo after L knee surgery —> tender L inguinal node with purulence. No F/C. No response to TMP-SMX.

Biopsy (see photo): Stellate suppurative granuloma with central necrosis and clumps of bacteria.

What is the most likely diagnosis?
1/
 #Gram stain: a first step in bacterial identification —> two major groups:
1. Gram-positive: retains primary stain (crystal violet)
2. Gram-negative: does not retain crystal violet but counterstained by safranin/fuchsine —> red / pink

Named after Hans Christian Gram (photo) Image
Read 12 tweets
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Mayo Clinic Infectious Diseases
@MayoClinicINFD
Images of Infectious Diseases

56M Mexico. Chronic abdominal pain, weight loss, anorexia.

Work up: elevated markers (CA19-9, CA-125, AFP). CXR normal. CT peritoneal carcinomatosis.

Laparoscopy (photo). Biopsy showed granuloma. What is your DDx? #MayoIDQ MCQ next... Image
#MayoIDQ
Thank you for your responses.

Culture of tissue (peritoneal nodules) of this 56M (see prior tweet) with granuloma on biopsy: Mycobacterium tuberculosis complex. Resistant to pyrazinamide.

Which of these choices is the most likely mechanism of transmission?
1/
 Case diagnosis: Peritoneal #tuberculosis due to #Mycobacterium #bovis

Path: granuloma and positive #AFB stain
Culture: M tuberculosis complex

Clue: #PZA resistance —> THINK M. bovis

Reported by @GaboMotoa during his rotation in Mayo Clinic

doi.org/10.1002/ccr3.3…
Read 11 tweets
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Mayo Clinic Infectious Diseases
@MayoClinicINFD
Images of Infectious Diseases

This is the peripheral blood smear of a 71M s/p splenectomy. Rural Wisconsin. No travel.

CC: fever, sweats, dyspnea
ROS: dark urine
PE: jaundice
Hgb 10. Low haptoglobin.
TBI 3.3 LDH 1075

What is the diagnosis and recommended Rx?
#MayoIDQ MCQ next
1/
 71M. WI. (see prior tweet)
S/p splenectomy.
Fever, jaundice, hemolytic anemia.

Your diagnosis: babesiosis (parasitemia 7.3%).

3 days after starting Rx: tinnitus and hypoacusis

What Rx most likely caused this adverse effect?
2/
 Treatment of #Babesiosis
1. Atovaquone-azithromycin
2. Quinine-clindamycin

The two regimens have comparable efficacy in non-life-threatening babesiosis.

BUT safety profile of Atovaquone-azithromycin was better

nejm.org/doi/full/10.10…
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