LAUSR

A previously healthy man in his 30s presented with spontaneous bruising, epistaxis, and haematuria. Acute promyelocytic leukemia (APML) was diagnosed by bone marrow aspirate morphology, immunophenotyping, and detection of the bcr1 variant of the PML-RARα fusion transcript in peripheral blood. He was commenced on treatment with the PETHEMA LPA 20051 protocol consisting of all-trans retinoic acid (ATRA) and idarubicin, an anthracycline based chemotherapy. Dexamethasone was prescribed to reduce the risk of ATRA syndrome, a potentially life threatening complication seen in these patients and characterized by fever, pulmonary infiltrates, hypotension, and leucocytosis. After 12 days of treatment, the patient developed pyrexia and was started on empiric antibiotics. Two days later he developed tender black spots on the scrotum that progressed to painful ulcers over 8 days (Figure, A). Systemic antifungal and antiviral therapy were added with no improvement. Peripheral blood cultures and skin swabs from the lesions did not identify bacterial or viral infection. Scrotal ultrasonography showed a subcutaneous hypervascular lesion with no abscess. The development and progression of scrotal ulceration coincided with recovery in neutrophil count from 0.3 × 109/L to 1.2 × 109/L and persistent pyrexia. As scrotal ulceration progressed, they enlarged and became necrotic with a black eschar. A specimen was obtained for histopathology. A Clinical image B Histopathologic specimen