Successful Treatment of Cutaneous Mucormycosis Disseminated From Pulmonary Mucormycosis With Liposomal Amphotericin B and Posaconazole

Mucormycosis, a rare but life-threatening fungal infection, poses a severe risk to people with weakened immune systems—including those battling cancer. For one 52-year-old man with acute lymphoblastic leukemia, a painful skin ulcer on his thigh would lead doctors to a surprising diagnosis: the infection had spread from his lungs to his skin, a rare scenario that highlights the importance of early detection and targeted treatment.

The case, detailed by doctors Xiao-Lan Ding, Hou-Min Li, and Juan Du from the Department of Dermatology at Peking University People’s Hospital, offers critical insights into how mucormycosis can disseminate—and how to treat it successfully.

A Patient’s Journey: From Lung Infection to Skin Ulcer

The man had lived with acute lymphoblastic leukemia for two years when he developed a cough and phlegm two months before his skin symptoms began. While blood and lung tissue cultures came back negative, a blood test (serum 1,3-b-D-glucan assay) suggested a fungal infection, and a chest CT scan showed new inflammation in his right lung. Doctors diagnosed a pulmonary fungal infection but faced a challenge: they couldn’t confirm the exact type of fungus.

Ten days later, the man’s condition worsened. He developed a fever and noticed a small, painful red patch on his right thigh. The patch quickly grew into a 2 cm × 4 cm ulcer with a dead, blackened center (necrotic eschar) and swollen, red skin around it. Unlike some infections, there was no pus or oozing—only severe pain, a key clue for doctors.

Uncovering the Rare Spread

When doctors examined the ulcer’s tissue under a microscope, they found something telling: blood vessel clots (thrombosis) in the dermis. Stains (hematoxylin-eosin and periodic acid-Schiff) revealed broad, non-septate hyphae with right-angle branches—the “signature” of mucormycosis. While direct microscopy of the lesion and a molecular test (PCR) for mucormycosis in the tissue were negative, the combination of the patient’s history, clinical signs, and pathological findings led to a diagnosis of disseminated mucormycosis—meaning the infection had spread throughout his body.

Here’s what made this case unusual: Most cutaneous (skin) mucormycosis comes from direct contact with fungal spores (like through a cut or wound). But in this man’s case, the infection had traveled from his lungs to his skin via his bloodstream—a reverse process seen in just 3% of mucormycosis cases, according to a landmark review of 929 cases by Roden et al. The patient had no history of skin trauma, and the ulcer appeared after his lung infection worsened—strong evidence that the fungus had spread through his blood.

Successful Treatment: A Two-Drug Approach

Mucormycosis is notoriously hard to treat, with a near-100% mortality rate when it disseminates. But doctors acted fast: they prescribed intravenous liposomal amphotericin B (50 mg daily) and posaconazole (800 mg daily), two antifungal drugs known to target mucormycosis.

The results were dramatic. Four weeks later, a repeat chest CT showed significant improvement in his lung infection, and his thigh ulcer had healed—covered only by a dry crust. This dual therapy worked for both his lungs and skin, confirming that the infection had spread from one organ to the other.

Why This Case Matters for Patients and Doctors

Mucormycosis is rare, but its severity means early diagnosis is life-saving. For doctors, the takeaways are clear:

Watch for skin signs in immunocompromised patients: A painful, necrotic ulcer—especially without a history of trauma—could signal that a fungal infection has spread from another organ (like the lungs).
Diagnosis requires “the big picture”: Even when tests like culture or PCR are negative, combining a patient’s history, physical exam, and pathology can lead to the right diagnosis.
Targeted antifungals save lives: Liposomal amphotericin B (a first-line treatment) and posaconazole (a newer azole) work together to fight mucormycosis, as this case shows.

While mucormycosis remains a deadly infection, this case offers hope: With vigilance, accurate diagnosis, and the right medications, even rare forms of the disease can be treated successfully.

The study was published in the Chinese Medical Journal in 2020 by Xiao-Lan Ding, Hou-Min Li, and Juan Du from Peking University People’s Hospital. For more details, you can access the original research at doi.org/10.1097/CM9.0000000000000891

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