PMC7298209_01
(A) On admission (first encounter), 2 skin ulcers: one over the
lateral malleolus and one on the lowest third of the lateral
side of the leg. Lesions appear necrotic with no active
secretions, tight skin is noticed around the lesions extending
down to the foot indicating edema, this edema was pitting on
examination. (B) After antibiotic use (pipracillin-tazobactam)
as an empirical therapy while waiting for the culture results.
Lesions were still the same size with no improvement of edema or
pain on examination. (C) After 5 days of voriconazole and local
terbinafine, base is not composed of necrotic tissue and is not
dry, likely due to the effect of local antifungal cream. Much
worse edema and pain were also witnessed on physical
examination. (D) After 5 days of starting amphotericin-B,
significant improvement in the lesions were noticed. Edema was
grade 1 (after being grade 3 constantly on previous daily
examination), pain was still there but significantly milder. We
started noticing this gradual improvement on day 3 of starting
amphotericin-B.
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She presented to the hematology outpatient clinic with 2 right lower extremity skin lesions: one over the lateral malleolus and one on the lowest third of the lateral side of the leg (superior to the first ulcer; Figure 1A). IV antibiotics, there was no evidence of any improvement of the lesions (Figure 1B), swab culture results came back positive for a heavy growth of Fusarium. Infectious Disease team was consulted and IV voriconazole was immediately started, accompanied by local terbinafine cream. After 5 days of IV voriconazole, edema and pain were getting worse but with the absence of necrotic tissue (Figure 1C). In the light of the significant clinical improvement, along with the ongoing renal impairment, decision was made to stop amphotericin-B and closely monitor the ulcer (Figure 1D).
(A) On day of discharge, 2 days after stopping amphotericin-B (9
days of treatment). Lesions were surrounded by viable red skin,
base was raised, and pus was dry almost all over the lesion.
Trace pitting edema was still there but pain was completely
absent on examination. Swab cultures were taken from the small
area of wet pus from the lesion over the lateral malleolus came
back negative for Fusarium infection or any
microorganism growth. (B) This photo was taken after 4 weeks of
stopping treatment. Lesions appeared well healed, base was
raised, and dry, in the process of pealing. No edema or pain on
physical examination. (C) This photo of the previously ulcerated
lesion on lower third of lateral leg was taken in the clinic,
after 12 weeks of stopping the treatment. Completely healed with
no pus, edema, or pain.
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Her kidney function and electrolytes were back to her baseline within 2 days off the treatment, her lesions were steadily improving regarding edema and pain (Figure 2A). Another follow-up clinic visit was arranged after 4 weeks with the same improving results (Figure 2B). The last outpatient follow-up encounters 12 weeks after stopping the treatment, lesions were well healed (Figure 2C).