Please login or create an account. If you do not have access to this content, you will be shown a 30 second preview and licensing options.

Presentation

Cutaneous Infections in Acute Leukemia and Febrile Neutropenia

Description

The speaker, a dermatologist, discusses cutaneous infections in patients with acute leukemia and febrile neutropenia, emphasizing that these patients are high-risk immunocompromised hosts who often require urgent evaluation. Using a case of a woman with relapsed AML, fever, neutropenia, and rapidly progressive violaceous skin papules, she reviews a broad differential that includes common bacterial infections, angioinvasive fungal disease, disseminated viral infections, and noninfectious leukemia-related conditions such as leukemic infiltration or neutrophilic dermatoses. She explains that AML and its intensive chemotherapy cause major immune defects—especially in granulocytes and prolonged neutropenia—raising the risk of bacterial, fungal, and sometimes viral infections, with infection commonly arising from the lungs, GI tract, or skin. Febrile neutropenia is defined as fever in the setting of neutropenia and is a medical emergency because the source is often not identifiable and gut mucosal injury from chemotherapy can permit bacterial translocation. The case ultimately showed Moraxella bacteremia with gram-negative rods on skin biopsy, and she uses this to highlight the value of prompt skin biopsy plus tissue cultures, noting that histology and culture are often discordant, histology may be better for fungal infection, cultures are especially useful for gram-negative rods, and even one dose of antimicrobials can lower diagnostic yield.

View more

Conclusions

Patients with acute leukemia, especially relapsed AML with febrile neutropenia, are at very high risk for severe cutaneous and systemic infections because of profound immune dysfunction and chemotherapy-related mucosal injury.
Febrile neutropenia should be treated as a medical emergency, and skin lesions in this setting require immediate evaluation for infectious and noninfectious causes.
In AML, bacterial and fungal infections are especially common, while the duration and depth of neutropenia strongly influence the risk of invasive fungal disease.
Cutaneous lesions in immunocompromised hosts demand a broad differential that includes bacterial, fungal, viral, and leukemia-related noninfectious processes.
Skin infections may arise from bloodstream spread, but also from the lungs, GI tract, urinary tract, line sites, perianal skin, or chronic wounds.
Gut translocation from chemotherapy-damaged mucosa is a major mechanism of unexplained bacteremia in neutropenic patients.
Skin biopsy with histology and tissue culture should be obtained early and in tandem, because each method misses many infections and antibiotics given beforehand can sharply reduce culture yield.
Histology is better for detecting fungal organisms, while tissue culture is more useful for gram-negative rods.
Rapidly progressive painful violaceous or necrotic lesions in neutropenic patients should raise concern for ecthyma gangrenosum or other angioinvasive infections and carry a poor prognosis when lesions are multiple or neutropenia is prolonged.

The skin and soft tissue infections in hematological patients.#10.1097/qco.0000000000000632
Comparison between organismal staining on histology and tissue culture in the diagnosis of cutaneous infection.#10.1016/j.jaad.2020.01.047