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- Presentation
Cutaneous Infections in Immunocompromised Patients with Acute Leukemia and Stem Cell Transplant
Description
This talk reviewed cutaneous infections in immunocompromised patients with acute leukemia and after stem cell transplant, using real cases to emphasize diagnosis and management. In AML, infections are a leading cause of death because of qualitative and quantitative neutrophil defects, especially during febrile neutropenia, which is a medical emergency. Skin findings such as painful violaceous or necrotic papules require a broad differential including bacterial, fungal, viral, and noninfectious causes. The presenter highlighted ecthyma gangrenosum as a classic gram-negative bacteremia-associated lesion, often due to Pseudomonas but also other organisms such as Moraxella, with rapid progression, surrounding cellulitis, sepsis risk, and high mortality. She also reviewed invasive fungal infections, emphasizing that prolonged neutropenia raises risk for aspergillosis, fusariosis, mucormycosis, and candidemia, and discussed serum markers like galactomannan and beta-D-glucan, antifungal prophylaxis, and when to start empiric therapy. In stem cell transplant patients, early post-transplant infections are often bacterial or fungal, while later ones are more often viral; HSV, VZV, CMV, and perirectal viral erosions were stressed as common and easy to miss. The talk also discussed the effects of anti-CD20 agents and BTK inhibitors on infection risk, including hypogammaglobulinemia and macrophage dysfunction, and presented cryptococcosis as another important cause of necrotic skin lesions in hematologic malignancy. Key takeaways were to recognize atypical presentations, biopsy early with tissue cultures before antimicrobials when possible, and use labs and imaging to identify the source of infection.
View moreConclusions
- In immunocompromised patients with leukemia or after stem cell transplant, skin findings may be the first sign of a serious and potentially fatal infection.
- Febrile neutropenia should be treated as a medical emergency, and the severity and duration of neutropenia strongly influence infection risk, especially for invasive fungi.
- Early skin biopsy with tissue culture, ideally before antimicrobials are given, is critical because histology and culture are often complementary and antimicrobials quickly reduce diagnostic yield.
- Ecthyma gangrenosum should prompt urgent evaluation for gram-negative bacteremia, but similar necrotic lesions can also reflect invasive fungal infection.
- Among invasive fungal infections, aspergillus usually begins in the lungs, fusarium commonly involves the skin and feet, mucorales often affects the sinuses or face and requires urgent debridement, and candida more often tracks with central lines and disseminated disease.
- Serum fungal markers can help, but they are imperfect: galactomannan is more specific for invasive aspergillosis, while beta-D-glucan is a broader screen with notable false positives.
- Antifungal prophylaxis and empiric treatment choices depend on the patient’s prior prophylaxis and the suspected portal of entry, with mold-active agents needed when skin or pulmonary signs suggest angioinvasive disease.
- After stem cell transplant, the pattern of infection risk changes over time, with early neutropenia favoring bacterial and fungal disease and later immune deficits increasing viral risk.
- Hypogammaglobulinemia and targeted agents such as anti-CD20 therapies and BTK inhibitors broaden infection risk and can produce atypical presentations, including herpesvirus, cryptococcal, and other opportunistic infections.
- Because these infections can look deceptively inflammatory or mimic noninfectious dermatoses, clinicians should keep a broad differential and escalate quickly when lesions are painful, necrotic, or rapidly progressive.
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- Table 1. Serum fungal assay test characteristics.
- Risk of infection in patients with lymphoma receiving rituximab: systematic review and meta-analysis.#10.1186/1741-7015-9-36
- Hypogammaglobulinemia and severe infections in Multiple Sclerosis patients on anti-CD20 agents: A multicentre study.#10.1016/j.msard.2024.106191
- Risk of Infections Secondary to the Use of Targeted Therapies in Hematological Malignancies#10.7759/cureus.52050