A Localized Macular Rash in an Immunocompromised Patient with Pneumonia and Necrotizing Enterocolitis

A 21-year-old male with T-cell acute lymphoblastic leukemia (ALL) was admitted for fever and neutropenia. Despite 72 h of antibiotic therapy, he remained febrile and developed new abdominal and pleuritic chest pain. His antimicrobial regimen was broadened to meropenem and voriconazole. On hospital day 5, a new asymptomatic rash appeared on his left face consisting of erythematous macules that blanched with pressure Within 24 h, the skin lesions expanded and developed a central, non-blanching violaceous hue. Liposomal amphotericin B was added and a biopsy of the rash was obtained. Mucor spp was confirmed by skin culture. Repeat imaging showed interval development of diffusely scattered and innumerable hypodense lesions throughout the liver and spleen, as well as diffuse myositis and lesions within the brain and spine. Care was withdrawn and the patient expired on hospital day 11. Risk factors for developing invasive aspergillosis and mucormycosis are similar. This case illustrates similarities in their clinical presentations, highlights potential gaps in coverage by antifungal agents that are commonly used for empiric coverage, and reviews treatment options.