A Patient With Ulcerated Nodules on His Face

Abstract

Diagnosis: Cutaneous squamous cell carcinoma (SCC) likely due to the long-term use of voriconazole. In some clinical settings, ulcerated nodular skin lesions can be concerning for a cutaneous nontuberculosis mycobacterial or fungal infection (Figure 1). However, in our patient, the histological sections of skin from the right mandibular region demonstrated dermal proliferation with nuclear atypia and numerous mitotic figures typical of SCC (Figure 2). In addition, the cells had abundant eosinophilic cytoplasm with intracellular bridging confirming the squamous lineage. The overlying surface epithelium was relatively unremarkable and all fungal and nontuberculosis mycobacterial specific stains and cultures were negative. A computed tomographic (CT) scan of the head and neck revealed periauricular skin thickening compatible with SCC with focal dermal lesions along the face in addition to necrotic lymphadenopathy with apparent invasion into the floor of the mouth. Based on the biopsy and CT findings, the patient was diagnosed with stage IV cutaneous SCC (T4N1M0, with various bilateral cervical lymph nodes). He underwent his initial treatment with local radiotherapy (40 Gy in 16 fractions), which was complicated by hemoptysis. His chronic fungal infection, decreased pulmonary function, and overall poor performance status prohibited the use of systemic myelosuppressive chemotherapy; therefore, a palliative course of cetuximab (epidermal growth factor receptor inhibitor) was administered. Unfortunately, despite these interventions, his SCC progressed over a period of several months and eventually led to airway compromise and death. Voriconazole is a broad-spectrum second-generation azole that exerts its antifungal activity by inhibiting ergosterol synthesis [1]. It has activity against all Candida species, most Aspergillus species, Fusarium species, the endemic mycoses, and Scedosporium apiospermum [1]. Voriconazole is generally well tolerated, but side effects can include self-limiting visual disturbances (photophobia, altered Figure 2. Histologic section from right mandibular region skin biopsy (hematoxylin-eosin stain, ×100 magnification), demonstrating squamous cell carcinoma. The image shows a dermal proliferation with nuclear atypia and numerous mitotic figures (small arrow). The cells have abundant eosinophilic cytoplasm with intracellular bridging confirming the squamous lineage (large arrow). Figure 1. Skin lesions on the right side of the face; diffuse nontender, hard, ulcerated nodules with necrosis that oozed serous fluid.