Case Presentation
The patient is a 14 years old boy who presented with signs of epistaxis
and fatigue from three months ago. Laboratory data showed severe
pancytopenia. Considering the risk of spontaneous hemorrhage, he was
immediately transferred to the tertiary center for comprehensive care.
Subsequent investigations through bone marrow biopsy and flow cytometry
were consistent with the diagnosis of acute myeloid leukemia (AML) M3
type. The patient received appropriate therapy first with daunorubicin
and ATRA and later with Arsenic trioxide. He then presented to the
hospital three months later with numerous bulging subcutaneous masses on
his buttocks, thighs, calves, and plantar surface of his feet. Similar
lesions, albeit fewer, were observed in the back and upper extremities.
Ultrasonography was done, and multiple thick-walled cystic lesions
containing some internal echogenic material were seen in the
subcutaneous tissue and within muscular compartments of lower
extremities with peripheral vascularity on Doppler ultrasound,
suggestive of abscess formation.
Multiple target-shaped and hypoechoic lesions were also observed in the
liver and spleen (Figure 1). Magnetic resonance imaging(MRI) of the
lower extremities was performed and showed numerous iso- to hyper-signal
on T1 and hyper-signal on T2-weighted oval lesions with hypo-signal rim
within different muscles of the lower extremities and also in
subcutaneous tissue. The almost diffuse hypo-signal intensity of bone
marrow of the bilateral tibia and fibula on the T1-weighted sequence was
also seen due to leukemic infiltration (Figure 2). Subsequent needle
aspiration of muscular lesions under ultrasound guidance was performed,
and cytopathology and culture reports were consistent with abscess
formation due to Candida Albicans (Figure 3). Brain MRI also was
performed and showed subdural hematoma in the right frontoparietal
convexity(due to low platelet level). A chest x-ray didn’t show any
abnormality.
So, antifungal therapy with intravenous Amphotericin-B was given to him
for two weeks and then step-down therapy with oral fluconazole was
started. After three months of anti-fungal treatment with oral
fluconazole along with chemotherapy, the patient was evaluated again
clinically and by imaging modalities including ultrasonography and MRI.
He felt generally well and bulging subcutaneous lesions in the back,
upper extremities, and thighs disappeared or shrinkage, compared with
pre-treatment physical examination. Although MRI showed almost complete
resolution of bone marrow leukemic infiltration, many of the leg
abscesses still persisted without change, and some of the lesions
coalesced together. Fortunately, Some leg abscesses changed to
non-enhancing signal void small foci in post-treatment MRI due to
calcification, which was confirmed on the targeted ultrasound. Also, the
complete resolution of hepatic lesions and calcification of splenic
lesions was seen in ultrasonography (Figure 4).
Due to the persistence of abscess on the buttocks and plantar surface of
the feet, which impaired the patient’s walking and sitting ability,
surgical incision was also performed. Post-surgical pathology was
reported as granulation tissue with focal abscess formation with
complete resolution of candida infection.