A 58-year-old man was admitted for management of Pseudomonas aeruginosa infection of his tunneled central venous catheter. Eleven months previously, he had received an allogeneic bone marrow transplant for acute myelogenous leukemia secondary to a mutation in runt-related transcription factor 1 (RUNX1), a protein that helps control hematopoiesis. In preparation for transplantation, he underwent a reduced-intensity regimen of therapy with fludarabine, melphalan, and alemtuzumab for disease eradication, immunosuppression, and donor stem cell engraftment.
Induction chemotherapy comprised fludarabine, cytarabine, filgrastim, and idarubicin and was complicated by Saprochaete capitata fungemia. Stem cell transplant complications included suspected invasive fungal pulmonary infection (which responded to isavuconazole), chest sepsis attributed to Raoultella ornithinolytica, and cytomegalovirus (CMV) reactivation with virological failure of foscarnet (secondary to UL54 mutation) necessitating salvage therapy with maribavir. The patient had concurrent chronic skin and mucosal graft-versus-host disease requiring ongoing prolonged immunosuppression including steroids, cyclosporine, rituximab, imatinib, abatacept, and topical immune suppression (steroids and tacrolimus).
Following the identification of P. aeruginosa bacteremia, the tunneled catheter was removed and the patient was treated with piperacillin-tazobactam via a peripheral cannula. One day prior to admission for this antimicrobial therapy, he developed disseminated violaceous skin lesions involving his trunk, limbs face, and hard palate (sparing his palms and soles) (Fig. 1A and B). Over 100 lesions were present. The lesions were mostly nodular, although some had an umbilicated appearance (Fig. 1A) and some others were crusting over (Fig. 1B). The lesions were not pruritic or painful, and the patient remained afebrile and hemodynamically stable throughout. A punch biopsy was taken, and histopathologic analysis identified multinucleated giant cells with intranuclear inclusions, nuclear molding, and margination of chromatin (Fig. 1C).
For answer and discussion, see https://doi.org/10.1128/JCM.00119-20 in this issue.
ACKNOWLEDGMENT
We thank the patient for granting permission for his clinical images to be shared.