Dirt Under the Finger-Nails—More Malignant Than Malignancy

A young boy developed steroid refractory GVHD post haploidentical transplant for relapsed B-ALL. He was on systemic immunosuppression with two immunosuppressants, and had history of CMV reactivation and tuberculosis. Eight months post-transplant, he was hospitalized with multi-drug-resistant gram-negative sepsis, and during the same episode, he developed penile lesions which progressed to dry gangrene of glans-penis. Fusarium grew in blood and penile lesions. On retrospective thinking, it was discerned that his onychomycoses were the probable cause of his penile lesions with hematogenous dissemination, as nails also grew Fusarium. This case highlights the need for a vigilant skin and nail examination in immunocompromised patients. This is important for two perspectives. First, cultures from potential colonized sources can help early identification and escalation of treatment. Secondly, appropriate precautions and treatment of superficial infections can help prevent dissemination.