PMC9356193_01
Photo taken on Day 3 of hospitalization illustrating left shoulder lesion. The erythematous rim extended centrifugally with new development of internal ecchymosis.
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Physical examination is remarkable for tenderness and erythema related to large (16 cm x 13 cm), well demarcated lesion of the left posterior shoulder (Fig. 1).
Photo of right flank was also taken on Day 3. Note the outer erythematous rim with internal ecchymosis and a single bullae. Moreso than the shoulder lesion, this lesion highlights classic necrosis seen with cutaneous mucormycosis.
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New skin lesions develop on the right flank, left flank (Fig. 2), right thigh (Fig. 3), and right lower abdomen, which are similarly tender to palpation, enlarging and noted for development of bullae in some lesions.
: CT scan of the chest on admission, demonstrating an abnormal airspace density in the left suprahilar region, concerning for either inflammatory or neoplastic etiology. The lesion is occult on plain chest radiograph.
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A CT scan of his chest reveals mild adenopathy with a lesion in the left suprahilar region (Fig. 4).
: This H&E slide of a skin biopsy demonstrates the classic broad and non-septate hyphae of mucor (arrow). The approximately 90-degree angle of branching helps differentiate it from the acute branching of aspergillus.
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He is started on IV voriconazole before preliminary hematoxylin and eosin stain from a shoulder punch biopsy shows broad, non-septate hyphae with right-angle branching, consistent with mucor (Fig. 5).
: The Grocott Methenamine-Silver Nitrate Stain (GMS) is useful in staining carbohydrates and thus highlights the polysaccharide-rich cell walls of fungi. This image was also obtained by skin biopsy and shows a mucor hypha en face (arrow) within a lymphovascular vessel.
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This includes visualization of hyphae within lymphovascular structures, which supports the argument for disseminated disease (Fig. 6).