Case presentation:
A 69-year-old male with a history CLL, ITP, and recurrent tinea corporis
presented to the hospital with an ulcerating lesion at the site of a
previously diagnosed tinea corporis infection of his right medial ankle.
One month prior to presentation, the patient was started on high-dose
steroids for treatment of refractory ITP. After 2-3 weeks of
experiencing a limited response to steroid treatment, he was started on
rituximab and ultimately hospitalized for refractory ITP. During this
hospitalization, the patient’s ITP was thought to be triggered by CLL
prompting the initiation of ibrutinib for treatment. Following the
initiation of ibrutinib, he was seen by dermatology for a new pruritic,
painful skin lesion on his right medial ankle. This skin lesion was
painful to the touch and noted to be a well-demarcated bright red plaque
with scattered hemorrhagic, dusky, purple papules within the plaque.
There was a collarette of scale overlying the edge of the lesion. A skin
scraping with potassium hydroxide preparation demonstrated numerous
branching hyphae. A biopsy of the lesion was deferred due to
thrombocytopenia (11,000/cmm). He was started on topical terbinafine 1%
cream twice daily for presumed superficial tinea corporis infection. He
was discharged once his thrombocytopenia stabilized. Less than one week
from discharge, the patient’s distal right lower extremity became
progressively more edematous with new ulceration and serosanguinous
drainage (Figure 1). He presented to the hospital again and admitted for
a second time (Table 1). He was evaluated with a computed tomography
scan of the right lower extremity which demonstrated diffuse
subcutaneous edema with pooling of fluid along the superficial fascia.
There were no signs of focal fluid collection or subcutaneous emphysema.
Due to clinical concern for necrotizing fasciitis, the patient was
urgently taken to the operating room by general surgery where he
underwent four-compartment fasciotomy of the right lower extremity as
well as excisional debridement of the involved area at the right ankle
until healthy appearing and bleeding tissue was reached.
Intraoperatively, there was extensive necrosis involving the dermis,
subcutaneous adipose tissue, and superficial fascial layers which were
debrided. The underlying muscle layers, tendons, and deep fascia
appeared alive and healthy. Tissue was sent for culture and pathology.
At the fasciotomy sites in the leg, there was a positive finger sign
between the adipose and the fascia as well as between the fascia and the
muscle, without frankly necrotic tissue in this part of the leg. While
the fascia and muscle appeared healthy, this clinical finding of easy
separation between the two tissue planes was thought to be
representative of early-stage infection in which necrosis of the
epimysium occurred without progression to widespread tissue necrosis.
Therefore, no further sharp debridement was performed. Pulse lavage
irrigation and debridement with nine liters of normal saline was then
performed at the surgical sites.
Operating room cultures grew Trichophyton rubrum , as well as
methicillin-susceptible Staphylococcus aureu s andEnterococcus faecalis. Pathology exam demonstrated numerous
branching, septated fungal hyphae within purulent inflammation in
subcutaneous tissue, fascia, and also intravascularly within a
thrombosed blood vessel (Figure 2). On post-operative day three, the
patient developed elevated temperatures and was noted to have skin
findings on his left lower extremity similar to the early stages of his
right lower extremity infection. On post-operative day four, he
underwent excisional debridement of his new left lower extremity lesion
at bedside. Deep tissue specimens of his left lower extremity lesion
grew Trichophyton rubrum and pathological exam demonstrated
purulent inflammation with necrosis and branching septated fungal
hyphae. On post-operative day six, his right lower extremity wounds
showed stability (Figure 3).
Ultimately, this patient received daily wound care with multiple
dressing changes which allowed for his surgical wounds to granulate and
fill in appropriately. He was treated with a three-week course of
antibacterials for methicillin susceptible Staphylococcus aureusand Enterococcus faecalis cultured from the right lower
extremity, and oral terbinafine 250mg daily for 12 weeks for his
invasive dermatophyte infection of both extremities. Given the extensive
debridement, his right lower extremity wounds were covered with split
thickness skin grafts six weeks post-operatively. At a clinic visit two
weeks after completing terbinafine treatment, the patient had well
healed skin grafts with no signs of recurrent infection.