An immunosuppressed man with an isolated necrotic plaque on the chest.

A 54-year-old man on systemic immunosuppressive therapy for 1 month after a liver transplant for hepatitis C virus presented with a 5-day history of a solitary plaque on the chest. Physical examination found an indurated, violaceous 5- × 3-cm tender plaque studded with pustules. Over the following days, the plaque became more purulent and developed a central erosion with necrosis (Fig 1). Punch biopsy found a nodular and diffuse dermal mixed cell infiltrate with multinucleated histiocytes and neutrophils (Fig 2, A). Fungal organisms with nonseptated hyphae and right angle branching were identified by Gomori methenamine silver stain (Fig 2, B).Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT) Question 1: What is the most likely diagnosis?A.CandidiasisB.MucormycosisC.AspergillosisD.FusariumE.CryptococcusAnswers:A.Candidiasis – Incorrect. Opportunistic cutaneous candidiasis commonly presents with firm papules and nodules.1Elewski B.E. Hughey L.C. Sobera J.O. Hay R. Fungal Diseases.in: Bolognia J.L. Jorizzo J.L. Schaffer J.V. Dermatology. 3rd ed. Elsevier Limited, China2012: 1251-1284Google Scholar Histology findings show budding yeast and pseudohyphae.1Elewski B.E. Hughey L.C. Sobera J.O. Hay R. Fungal Diseases.in: Bolognia J.L. Jorizzo J.L. Schaffer J.V. Dermatology. 3rd ed. Elsevier Limited, China2012: 1251-1284Google Scholar, 2Guarner J. Brandt M.E. Histopathologic diagnosis of fungal infections in the 21st century.Clin Microbiol Rev. 2011; 24: 247-280Crossref PubMed Scopus (470) Google ScholarB.Mucormycosis – Correct. Mucormycosis, or zygomycosis, is an angioinvasive fungus, and cutaneous involvement is characterized by tissue infarction and necrosis. It has irregular nonseptated ribbonlike hyphae with right angle branching (as shown in Figs 2, A and B).1Elewski B.E. Hughey L.C. Sobera J.O. Hay R. Fungal Diseases.in: Bolognia J.L. Jorizzo J.L. Schaffer J.V. Dermatology. 3rd ed. Elsevier Limited, China2012: 1251-1284Google Scholar, 2Guarner J. Brandt M.E. Histopathologic diagnosis of fungal infections in the 21st century.Clin Microbiol Rev. 2011; 24: 247-280Crossref PubMed Scopus (470) Google ScholarC.Aspergillosis – Incorrect. Aspergillosis can cause necrotic papules and plaques similar to mucormycosis; however, it is distinguished by its septate hyphae with dichotomous 45° branching.1Elewski B.E. Hughey L.C. Sobera J.O. Hay R. Fungal Diseases.in: Bolognia J.L. Jorizzo J.L. Schaffer J.V. Dermatology. 3rd ed. Elsevier Limited, China2012: 1251-1284Google Scholar, 2Guarner J. Brandt M.E. Histopathologic diagnosis of fungal infections in the 21st century.Clin Microbiol Rev. 2011; 24: 247-280Crossref PubMed Scopus (470) Google ScholarD.Fusarium – Incorrect. Fusarium can also cause necrotic papules and pustules that are often associated with a periungual focus (ie, paronychia and onychomycosis). Histologic findings are similar to those of aspergillosis, with septated hyphae and acute-angle branching.1Elewski B.E. Hughey L.C. Sobera J.O. Hay R. Fungal Diseases.in: Bolognia J.L. Jorizzo J.L. Schaffer J.V. Dermatology. 3rd ed. Elsevier Limited, China2012: 1251-1284Google ScholarE.Cryptococcus – Incorrect. Cryptococcus commonly presents with ulceration, cellulitis, or molluscum contagiosum–like lesions.1Elewski B.E. Hughey L.C. Sobera J.O. Hay R. Fungal Diseases.in: Bolognia J.L. Jorizzo J.L. Schaffer J.V. Dermatology. 3rd ed. Elsevier Limited, China2012: 1251-1284Google Scholar Histology findings show encapsulated, spherical-to-oval yeast with narrow-based budding.2Guarner J. Brandt M.E. Histopathologic diagnosis of fungal infections in the 21st century.Clin Microbiol Rev. 2011; 24: 247-280Crossref PubMed Scopus (470) Google Scholar Question 2: What is the most common site for this type of infection?A.PulmonaryB.CutaneousC.SinusD.GastrointestinalE.KidneyAnswers:A.Pulmonary – Incorrect. Most commonly acquired through inhalation of spores, the lungs are the second most common infection site (24%), and the most common form found in neutropenic and stem cell transplant patients.3Petrikkos G. Skiada A. Lortholary O. Epidemiology and clinical manifestations of mucormycosis.Clin Infect Dis. 2012; 54: S23-34Crossref PubMed Scopus (763) Google Scholar, 4Roden M.M. Zaoutis T.E. Buchanan W.L. Epidemiology and outcome of zygomycosis: a review of 929 reported cases.Clin Infect Dis. 2005; 41: 634-653Crossref PubMed Scopus (1906) Google ScholarB.Cutaneous – Incorrect. Most commonly acquired through direct inoculation, skin mucormycosis is the third most common presentation (19%).3Petrikkos G. Skiada A. Lortholary O. Epidemiology and clinical manifestations of mucormycosis.Clin Infect Dis. 2012; 54: S23-34Crossref PubMed Scopus (763) Google Scholar, 4Roden M.M. Zaoutis T.E. Buchanan W.L. Epidemiology and outcome of zygomycosis: a review of 929 reported cases.Clin Infect Dis. 2005; 41: 634-653Crossref PubMed Scopus (1906) Google Scholar One study found that hematogenous dissemination from skin to other noncontiguous organs occurred in 1 in 5 patients,4Roden M.M. Zaoutis T.E. Buchanan W.L. Epidemiology and outcome of zygomycosis: a review of 929 reported cases.Clin Infect Dis. 2005; 41: 634-653Crossref PubMed Scopus (1906) Google Scholar and the rate in immunocompromised hosts is likely higher.C.Sinus – Correct. The most common site of infection is the sinuses (39%).3Petrikkos G. Skiada A. Lortholary O. Epidemiology and clinical manifestations of mucormycosis.Clin Infect Dis. 2012; 54: S23-34Crossref PubMed Scopus (763) Google Scholar Rhinocerebral infection is the most commonly reported pattern of sinus mucormycosis. This manifestation constitutes most cases in patients with diabetes mellitus.4Roden M.M. Zaoutis T.E. Buchanan W.L. Epidemiology and outcome of zygomycosis: a review of 929 reported cases.Clin Infect Dis. 2005; 41: 634-653Crossref PubMed Scopus (1906) Google ScholarD.Gastrointestinal – Incorrect. Mucormycosis can infect the gastrointestinal tract, but it is rare.4Roden M.M. Zaoutis T.E. Buchanan W.L. Epidemiology and outcome of zygomycosis: a review of 929 reported cases.Clin Infect Dis. 2005; 41: 634-653Crossref PubMed Scopus (1906) Google ScholarE.Kidney – Incorrect. Mucormycosis can infect the kidneys, but it is also rare.4Roden M.M. Zaoutis T.E. Buchanan W.L. Epidemiology and outcome of zygomycosis: a review of 929 reported cases.Clin Infect Dis. 2005; 41: 634-653Crossref PubMed Scopus (1906) Google Scholar Question 3: What is the first-line treatment?A.VoriconazoleB.CaspofunginC.ItraconazoleD.Amphotericin BE.PosaconazoleAnswers:A.Voriconazole – Incorrect. Voriconazole is ineffective against mucormycosis.1Elewski B.E. Hughey L.C. Sobera J.O. Hay R. Fungal Diseases.in: Bolognia J.L. Jorizzo J.L. Schaffer J.V. Dermatology. 3rd ed. Elsevier Limited, China2012: 1251-1284Google Scholar It is a first-line treatment for aspergillosis, for which it shows better efficacy, improved survival, and fewer side effects than amphotericin B.5Donnelley M.A. Zhu E.S. Thomas 3rd, G.R. Isavuconazole in the treatment of invasive aspergillosis and mucormycosis infections.Infect Drug Resist. 2016; 9: 79-86PubMed Google ScholarB.Caspofungin – Incorrect. Caspofungin is ineffective against mucormycosis.1Elewski B.E. Hughey L.C. Sobera J.O. Hay R. Fungal Diseases.in: Bolognia J.L. Jorizzo J.L. Schaffer J.V. Dermatology. 3rd ed. Elsevier Limited, China2012: 1251-1284Google ScholarC.Itraconazole – Incorrect. Itraconazole is ineffective against mucormycosis.1Elewski B.E. Hughey L.C. Sobera J.O. Hay R. Fungal Diseases.in: Bolognia J.L. Jorizzo J.L. Schaffer J.V. Dermatology. 3rd ed. Elsevier Limited, China2012: 1251-1284Google ScholarD.Amphotericin B – Correct. In addition to surgical excision, intravenous amphotericin B is the drug of choice for initial therapy.1Elewski B.E. Hughey L.C. Sobera J.O. Hay R. Fungal Diseases.in: Bolognia J.L. Jorizzo J.L. Schaffer J.V. Dermatology. 3rd ed. Elsevier Limited, China2012: 1251-1284Google Scholar, 3Petrikkos G. Skiada A. Lortholary O. Epidemiology and clinical manifestations of mucormycosis.Clin Infect Dis. 2012; 54: S23-34Crossref PubMed Scopus (763) Google Scholar, 5Donnelley M.A. Zhu E.S. Thomas 3rd, G.R. Isavuconazole in the treatment of invasive aspergillosis and mucormycosis infections.Infect Drug Resist. 2016; 9: 79-86PubMed Google ScholarE.Posaconazole – Incorrect. Oral posaconazole and isavuconazole are commonly used as step-down therapy several weeks after patients have responded to amphotericin B. Posaconazole and isavuconazole can also be used as salvage therapy for patients who do not respond to or cannot tolerate amphotericin B.5Donnelley M.A. Zhu E.S. Thomas 3rd, G.R. Isavuconazole in the treatment of invasive aspergillosis and mucormycosis infections.Infect Drug Resist. 2016; 9: 79-86PubMed Google Scholar