Fungal infection of muscle in acute leukemia

I).P., a 25-year-old white man, was diagnosed as having acute lymphoblastic leukemia in November 1973. Over the course of 1 year he received many chemotherapeutic agents, including vincristine and prednisone, but never achieved a lasting remission. In ,4ugust 1974, he had an episode of meningeal leukemia treated successfully with intrathecal thiotepa. Although he was in bone marrow relapse he continued to be ambulatory until 2 weeks prior to his final admission when he began to complain of sharp, nonradiating pains involving his right upper anterior thigh. These pains then spread to involve both calves, thighs, shoulders. and upper arms, with progressive weakness of these muscle groups. €Iis last admission was prompted by progressive weakness, fever, and granulocytopenia. Physical examination at the time of admission showed a nontoxic but chronically ill-appearing male in moderate distress, with a temperature of 103" F. Lymph nodes were palpably enlarged in the cervical, axillary, and inguinal areas, and there was marked hepatosplenomegaly. Neurologic exam showed moderate tenderness, marked wasting, and l I /V strength of all muscle groups. H e was unable to walk without assistance. Cerebellar, cranial nerve, and sensory tests were normal. I k e p tendon reflexes were absent in the legs and symmetrically 2+ in the arms. There were no pathologic reflexes. Lumbar puncture revealed normal pressure, no cells, negative cytocentrifuge exam, negative culture, and an elevated protein of 108 mg/ 100 ml. hluscle enzymes including CPK and aldolase were normal. No source for the fever was found, but because of