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Internal Medicine

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Following remission induction therapy for acute myelocytic leukemia, a 32-year-old woman was admitted for fever and neutropenia. She had been receiving levofloxacin prophylaxis and G-CSF.

On admission, she appeared ill and had a temperature of 39°C. Multiple 5-10mm painful, tender red papules and plaques were present on her arms, dorsum of the hands, and trunk. Oral mucosa and conjunctivae were normal. A skin biopsy was obtained.

A Hickman catheter site in her right infraclavicular region appeared normal. Her routine blood studies were notable for an absolute neutrophil count (ANC) of 500/cu mm, a rise since her last clinic visit a week prior. Ceftazidime was begun and levofloxacin discontinued. A chest CT was normal.

On the third hospital day her fever and rash were unchanged, but she was clinically stable. Blood cultures were negative. ANC was now 750/cu mm.

The skin biopsy was reported as showing numerous neutrophils without leukocytoclastic vasculitis. No organisms were visible on fungal stains or on routine culture at 48 hours.

The most appropriate treatment is which of the following?

  • 0%Add micafungin

  • 0%Add steroids

  • 0%Add acyclovir

  • 0%Change ceftazidime to meropenem


The patient’s painful skin lesions, neutrophilic infiltrate and fever are most compatible with Sweet syndrome, one of the so-called neutrophilic dermatoses, often seen in patients with AML, myelodysplastic syndrome or other malignancies.

Appearance of skin lesions as the neutrophils return during G-CSF treatment is a common timing. Were the lesions fungal in origin, the fungal stains of the biopsy would have shown the fungi and culture of the biopsy would have been positive for Candida and or occasionally moulds (e.g., fusarium) at 48 hours. A short, tapering course of prednisone leads to rapid improvement in Sweet syndrome, though relapse can occur.

G-CSF does not cause skin lesions, though some have postulated a role in increasing the incidence of Sweet syndrome.

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