Osteoarticular mucormycosis is relentlessly progressive, with bone destruction that necessitates extremity amputation. This case reports a 16-year-old female with pre-B cell acute lymphoblastic leukemia (B-cell ALL) who underwent consolidative haploidentical hematopoietic stem cell transplantation (HSCT) and developed Zygomycetes spp. osteomyelitis after receiving anti-TNF therapy for presumed pulmonary GVHD. Due to progression on systemic therapy, she received the adjunct of intra-operatively placed amphotericin B cement beads changed at regular surgical debridement over 6 weeks. This case demonstrates that early diagnosis and aggressive anti-fungal therapy with surgical debridement and amphotericin cement beads can allow limb sparing and complete recovery.

Acute graft versus host disease (aGvHD) remains one of the most serious complications, occurring in about 30-70%, of allogeneic hematopoietic stem cell transplantation (HSCT) recipients. While about 40-60% of these recipients will respond to steroids as first line, there is no consensus on second line agents. The management of steroid-refractory (SR) and steroid dependent (SD) GVHD after HSCT continues to be challenging. In the absence of clinical trials, treatment in most cases is based on individual physician or center experience. Herein, we present our institutional experience with the use of bortezomib, a first-generation reversible proteasome inhibitor, in SD aGvHD.