Fatal Bipolaris spicifera infection in an immunosuppressed child.

To cite: Teran CG, Downes K, Medows M. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013009703 DESCRIPTION A 20-month-old boy with a history of hypoplastic left heart syndrome and a heart transplant was transferred to our institution due to cardiorespiratory failure. His course had been complicated by chronic rejection requiring significant immunosuppression. Over the few weeks prior to transfer, he started developing dark macular skin lesions on the forehead, toes and fingers. The lesions rapidly progressed to necrotic ulcers within approximately 1 month of their onset (figure 1A,B). At transfer, he was on broad spectrum antibiotic coverage including vancomycin and piperacillin– tazobactam, as well as prophylactic voriconazole. Because of the symmetric distribution of lesions, disseminated fungal infection with septic emboli was considered and amphotericin was started; an echocardiogram was negative for vegetations. A skin biopsy was obtained and cultures grew Bipolaris spicifera (figure 2A). The patient’s mental status gradually deteriorated and a brain MRI showed evidence of possible infection (figure 2B).