A Patient with Acute Promyelocytic Leukemia and Persistent Skin Lesions Following Thorn Injury

A 64 year old male patient with recently diagnosed acute promyelocytic leukemia treated with arsenic, all-trans retinoic acid and gemtuzumab developed bilateral pulmonary infiltrates and alveolar hemorrhage. He was started on high dose prednisone. He also had prolonged severe neutropenia. There were asymptomatic lesions on his knees bilaterally for few weeks prior to current hospitalization. The skin lesions developed at site of thorn injury sustained when he worked in his garden. Skin biopsy revealed presence of fungal elements on H&E and GMS stain showed round elements. Culture on Sabaraud’s agar showed growth of mold identified as Alternaria. Alternaria are dematiaceous fungi, predominantly plant pathogens but an increasing cause of opportunistic infection in immunocompromised hosts. The case highlights infection due to an emerging opportunistic pathogen and illustrates importance of biopsy for innocuous appearing skin lesions in the immunocompromised patients.