Cutaneous infections are common in immunocompromised patients. Neutropenia predisposes patients to fungal, bacterial and viral infections. Antibacterial antifungal and antiviral prophylaxis have caused a significant reduction in some of these infections.
There are two main types of cutaneous infections : primary cutaneous infections and cutaneous manifestations of a disseminated infection. In the latter, skin lesions may be the window to disseminated bloodstream infection and the first and only evidence of a disseminated life threatening infection.
The diagnosis may be at your fingertips; therefore a thorough skin exam is the clue. However, it’s also important to know the characteristic lesions associated with different infections. It will help expedite diagnosis so appropriate treatment is initiated promptly in neutropenic patients, which can be lifesaving.
In a retrospective study of 43 neutropenic febrile patients with cutaneous lesions, fungal infections were the most frequent, and nodular lesions on the lower extremities were the most prevalent (Naorungroj and Aiempanakit, J Am Acad Dermatol 74:AB166, 2016).
Skin biopsy for pathological study and culture remains the gold standard and should be obtained early to confirm the suspected diagnosis. In these immunocompromised patients the inflammatory response is altered by either the primary disease or its treatment. Therefore, routine pathogens may present in an atypical fashion, with diminished or absent induration, erythema, or pustulation in response to bacterial resulting cutaneous infection without typical cellulitis (Urabe, Clin Infect Dis 39:S53–S55, 2004). Skin lesions are evaluated not only by morphology, but also in the context of the clinical setting and biopsy result. The skin biopsy is inexpensive, relatively noninvasive and without contraindication, and may avoid the need for more invasive procedures such an open lung biopsy (Grossman, et al., Cutaneous manifestations of infection in the immunocompromised host. Springer Science+Business Media, LLC, New York, 2012).
In addition to antimicrobial therapy, surgery should not be postponed in the face of progressive skin and soft tissue infection in this population (Brzozowski and Ross, J Hand Surg Br 22:679–680, 1997).
This is a preview of subscription content, log in to check access.
Kryeziu E, Kryeziu K, Bajraktari G, Abazi M, Zylfiu B, Rudhani I, Sh S, Ukimeri A, Brovina A, Sh D, Telaku S. Ecthyma gangrenosum in a patient with acute leukemia. Med Arh. 2010;64(6):373–4.PubMedGoogle Scholar
Brady GP, Bolivar R, Fainstein V, et al. Infections caused by Pseudomonas aeruginosa. Rev Infect Dis. 1983;5:279–313.CrossRefGoogle Scholar
Bodey GP. Dermatologic manifestations of infections in neutropenic patients. Infect Dis Clin N Am. 1994;8(3):655–75. Review.Google Scholar
Mull JD, Callahan WS. The role of the elastase of Pseudomonas aeruginosa in experimental infection. Exp Mol Pathol. 1995;4:567–75.CrossRefGoogle Scholar
Brzozowski D, Ross DC. Upper limb Escherichia coli cellulitis in the immunocompromised. J Hand Surg Br. 1997;22(5):679–80.PubMedCrossRefGoogle Scholar
Livingston W, Grossman ME, Garvey G. Hemorrhagic bullae in association with Enterobacter cloacae septicemia. J Am Acad Dermatol. 1992;27:637–8.PubMedCrossRefGoogle Scholar
Chapman RA, Van Slyck EJ, Madhavan T. Skin lesions associated with E. coli sepsis in a patient with acute leukemia. Henry Ford Hosp Med J. 1980;28(1):47–8.PubMedGoogle Scholar
Grant MD, Horowitz HI, Lorian V. Gangrenous ulcer and septicemia due to citrobacter. N Engl J Med. 1969;280(23):1286–7.PubMedCrossRefGoogle Scholar
Gössl M, Eggebrecht H. Necrotizing skin ulceration in antibiotic-induced agranulocytosis. Mayo Clin Proc. 2006;81(12):1527.PubMedCrossRefGoogle Scholar
Sakhnini E, Weissmann A, Oren I. Fulminant Stenotrophomonas maltophilia soft tissue infection in immunocompromised patients: an outbreak transmitted via tap water. Am J Med Sci. 2002;323(5):269–72.PubMedCrossRefGoogle Scholar
Harris RL, Faintein V, Elting L, et al. Bacteremia caused by Aeromonas species hospitalized cancer patients. Rev Infect Dis. 1985;7:314–20.PubMedCrossRefGoogle Scholar
Klastersky J. Infections in immunocompromised patients. I. Pathogenesis, etiology, and diagnosis. Clin Ther. 1985;8(1):90–9.PubMedGoogle Scholar
Cone LA, Dreisbach L, Potts BE, Comess BE, Burleigh WA. Fatal Bacillus cereus endocarditis masquerading as an anthrax-like infection in a patient with acute lymphoblastic leukemia: case report. J Heart Valve Dis. 2005;14(1):37–9.PubMedGoogle Scholar
Mori T, Tokuhira M, Takae Y, et al. Successful non-surgical treatment of brain abscess and necrotizing fasciitis caused by Bacillus cereus. Intern Med. 2002;41(8):671–3.PubMedCrossRefGoogle Scholar
Groschel D, Burgess MA, Bodey GP. Gas gangrene-like infection with Bacillus cereus in a lymphoma patient. Cancer. 1976;37:988–91.PubMedCrossRefGoogle Scholar
Hopkins DG, Kushner JP. Clostridial species in the pathogenesis of necrotizing enterocolitis in patients with neutropenia. Am J Hematol. 1983;14:289–95.PubMedCrossRefGoogle Scholar
Van der Lelie H, Leverstein-Van Hall M, Mertens M, et al. Corynebacterium CDC group JK (Corynebacterium jeikeium) sepsis in haematological patients: a report of three cases and a systematic literature review. Scand J Infect Dis. 1995;27(6):581–4.PubMedCrossRefGoogle Scholar
Olson JM, Nguyen VQ, Yoo J, Kuechle MK. Cutaneous manifestations of Corynebacterium jeikeium sepsis. Int J Dermatol. 2009;48(8):886–8.PubMedCrossRefGoogle Scholar
Elting LS, Bodey GP, Keefe BH. Septicemia and shock syndrome due to viridans streptococci: a case – control study of predisposing factors. Clin Infect Dis. 1992;14:1201–7.PubMedCrossRefGoogle Scholar
Van Ingen J. Diagnosis of nontuberculous mycobacterial infections. Semin Respir Crit Care Med. 2013;34(pg):103–9.PubMedGoogle Scholar
McWhinney PH, Yates M, Prentice HG, et al. Infection caused by Mycobacterium chelonae: a diagnostic and therapeutic problem in the neutropenic patient, Clin Infect Dis, 1992, vol. 14(pg. 1208–1212).PubMedCrossRefGoogle Scholar
Doucette K, Fishman JA. Nontuberculous mycobacterial infection in hematopoietic stem cell and solid organ transplant patients. Clin Infect Dis. 2004;38:1428–39.PubMedCrossRefGoogle Scholar
Doutre MS, Beylot C, Mougein J, et al. Cutaneous infection caused by Mycobacterium malmoense in a patient with myelodysplastic syndrome. J R Soc Med. 1993;86:110–1.PubMedPubMedCentralGoogle Scholar
Naorungroj S, Aiempanakit K. A study of cutaneous manifestations among febrile neutropenic patients: a five-year retrospective review in a single tertiary university hospital in Southern Thailand. J Am Acad Dermatol. 74(5):AB166. https://doi.org/10.1016/j.jaad.2016.02.653.
Feld R, Evans WK, DeBoer G. Herpes zoster in patients with small-cell carcimona of the lung receiving combined modality treatment. Ann Intern Med. 1980;93:282–3.PubMedCrossRefGoogle Scholar
Mays SR, Bogle MA, Bodey GP. Cutaneous fungal infections in the oncology patient: recognition and management. Am J Clin Dermatol. 2006;7(1):31–43.PubMedCrossRefGoogle Scholar
Pappas PG, et al. Clinical practice guideline for the management of candidiasis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;62(4):e1–50.PubMedCrossRefGoogle Scholar
Horn DL, et al. Epidemiology and outcomes of candidemia in 2019 patients: data from the prospective antifungal therapy alliance registry. Clin Infect Dis. 2009;48(12):1695–703.PubMedCrossRefGoogle Scholar
Sipsas NV, et al. Candidemia in patients with hematologic malignancies in the era of new antifungal agents (2001–2007): stable incidence but changing epidemiology of a still frequently lethal infection. Cancer. 2009;115(20):4745–52.PubMedCrossRefGoogle Scholar
Guarana M, Nucci M. Acute disseminated candidiasis with skin lesions: a systematic review. Clin Microbiol Infect. 2018;24(3):246–50.PubMedCrossRefGoogle Scholar
Chen LY, et al. Associated clinical characteristics of patients with candidemia among different Candida species. J Microbiol Immunol Infect. 2013;46(6):463–8.PubMedCrossRefGoogle Scholar
Nucci M, Anaissie E. Cutaneous infection by Fusarium species in healthy and immunocompromised hosts: implications for diagnosis and management. Clin Infect Dis. 2002;35(8):909–20.PubMedCrossRefGoogle Scholar
Hayashida MZ, et al. Disseminated fusariosis with cutaneous involvement in hematologic malignancies: report of six cases with high mortality rate. An Bras Dermatol. 2018;93(5):726–9.PubMedPubMedCentralCrossRefGoogle Scholar
Gilbert DN, et al., editors. The Sanford guide to antimicrobial therapy 2018. Sperryville: Antimicrobial Therapy, Inc; 2018.Google Scholar
Bernardeschi C, et al. Cutaneous invasive aspergillosis: retrospective multicenter study of the French invasive-aspergillosis registry and literature review. Medicine (Baltimore). 2015;94(26):e1018.CrossRefGoogle Scholar
Patterson TF, et al. Invasive aspergillosis. Disease spectrum, treatment practices, and outcomes. I3 Aspergillus Study Group. Medicine (Baltimore). 2000;79(4):250–60.CrossRefGoogle Scholar
Patterson TF, et al. Practice guidelines for the diagnosis and management of aspergillosis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;63(4):e1–e60.PubMedPubMedCentralCrossRefGoogle Scholar
Petrikkos G, et al. Epidemiology and clinical manifestations of mucormycosis. Clin Infect Dis. 2012;54(Suppl 1):S23–34.PubMedCrossRefGoogle Scholar
Roden MM, et al. Epidemiology and outcome of zygomycosis: a review of 929 reported cases. Clin Infect Dis. 2005;41(5):634–53.PubMedCrossRefGoogle Scholar
Lemos LB, Baliga M, Guo M. Blastomycosis: the great pretender can also be an opportunist. Initial clinical diagnosis and underlying diseases in 123 patients. Ann Diagn Pathol. 2002;6(3):194–203.PubMedCrossRefGoogle Scholar
Miceli A, Krishnamurthy K. Blastomycosis. Treasure Island: StatPearls; 2018.Google Scholar
Wang S, et al. Dermatoscopic and clinicopathologic findings of cutaneous blastomycosis. J Am Acad Dermatol. 2015;73(5):e169–70.PubMedCrossRefGoogle Scholar
Li AW, Yin ES, Stahl M, Kim TK, Panse G, Zeidan AM, et al. The skin as a window to the blood: cutaneous manifestations of myeloid malignancies. Blood Rev. 2017;31(6):370–88.PubMedCrossRefGoogle Scholar
Benet C, Gomez A, Aguilar C, Delattre C, Vergier B, Beylot-Barry M, et al. Histologic and immunohistologic characterization of skin localization of myeloid disorders: a study of 173 cases. Am J Clin Pathol. 2011;135(2):278–90.PubMedCrossRefGoogle Scholar
Loricera J, Calvo-Rio V, Ortiz-Sanjuan F, Gonzalez-Lopez MA, Fernandez-Llaca H, Rueda-Gotor J, et al. The spectrum of paraneoplastic cutaneous vasculitis in a defined population: incidence and clinical features. Medicine (Baltimore). 2013;92(6):331–43.Google Scholar
Greer JM, Longley S, Edwards NL, Elfenbein GJ, Panush RS. Vasculitis associated with malignancy. Experience with 13 patients and literature review. Medicine (Baltimore). 1988;67(4):220–30.CrossRefGoogle Scholar
Garcia-Porrua C, Gonzalez-Gay MA. Cutaneous vasculitis as a paraneoplastic syndrome in adults. Arthritis Rheum. 1998;41(6):1133–5.PubMedCrossRefGoogle Scholar
Miliszewski MA, Kirchhof MG, Sikora S, Papp A, Dutz JP. Stevens-Johnson syndrome and toxic epidermal necrolysis: an analysis of triggers and implications for improving prevention. Am J Med. 2016;129(11):1221–5.PubMedCrossRefGoogle Scholar
Schwartz RA, McDonough PH, Lee BW. Toxic epidermal necrolysis: part I. Introduction, history, classification, clinical features, systemic manifestations, etiology, and immunopathogenesis. J Am Acad Dermatol. 2013;69(2):173, e1–13; quiz 85–6.PubMedCrossRefGoogle Scholar
Roujeau JC, Kelly JP, Naldi L, Rzany B, Stern RS, Anderson T, et al. Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. N Engl J Med. 1995;333(24):1600–7.PubMedCrossRefGoogle Scholar
Macdonald JB, Macdonald B, Golitz LE, LoRusso P, Sekulic A. Cutaneous adverse effects of targeted therapies: part I: inhibitors of the cellular membrane. J Am Acad Dermatol. 2015;72(2):203–18; quiz 19–20.PubMedCrossRefGoogle Scholar
Brazzelli V, Grasso V, Borroni G. Imatinib, dasatinib and nilotinib: a review of adverse cutaneous reactions with emphasis on our clinical experience. J Eur Acad Dermatol Venereol. 2013;27(12):1471–80.PubMedCrossRefGoogle Scholar