A 70-year-old Thai man with a 5-year history of primary myelofibrosis, hypertension, pulmonary hypertension due to left-sided heart disease, asthma, and osteoporosis presented with an erythematous swollen left leg for 7 days. He also complained of fever, dyspnea on exertion, and orthopnea for 6 days. He had multiple ulcers on his right foot for 10 days, and was treated with ceftriaxone for 3 days prior to hospitalization. He received ruxolitinib for treatment of primary myelofibrosis for 4 years. His other medications included warfarin, omeprazole, furosemide, diltiazem, spironolactone, bisoprolol, and seretide evohaler for his pulmonary and heart diseases. Ruxolitinib was initiated in November 2015 after the patient developed pancytopenia following hydroxyurea and allopurinol treatment. Total duration of ruxolitinib therapy was 48 months, and the most recent dose was 20 mg/day. He denied smoking and alcohol drinking. He reported no exposure to herbal drug use or animals, and he had no known tuberculosis contact. Physical examination revealed a low-grade fever [temperature (T) 38.3 °C], blood pressure (BP) 117/64 mmHg, pulse 72/min, respiratory rate 24/min, oxygen saturation 85% at room air, and 98% with oxygen cannula 3 l per minute (LPM). He was alert, had mild pallor, and was tachypneic. Cardiovascular examination showed jugular vein distension with apical and parasternal heaving, loud P2, and irregular pulse. Fine crepitations were detected at both lower lung fields. Abdominal examination revealed mild splenomegaly. Ill-defined erythematous swelling of the left leg with mild tenderness, and multiple ulcers at his right foot with minimal pus discharge were noted. Neurological examination and other systems were unremarkable. Complete blood count (CBC) revealed a white blood cell count (WBC) of 21,130 cells/μL (81% neutrophil, 9% band form, 5% metamyelocyte, and 2% promyelocyte), hemoglobin (Hb) level of 7.2 g/dL, platelet (PLT) count of 536,000 cells/μL, blood urea nitrogen (BUN) of 23.9 mg/dL, and serum creatinine (SCr) of 1.21 mg/dL. Liver function tests showed direct bilirubin (DBIL) of 0.66 mg/dL, total bilirubin (TBIL) of 0.45 mg/ dL, aspartate transaminase (AST) of 16 U/L, alanine transaminase (ALT) of 10 U/L, alkaline phosphatase (ALP) of 84 U/L, albumin (ALB) of 2.8 g/dL, and total protein of 5.4 g/dL. The urinalysis was unremarkable. Chest radiograph (CXR) showed bilateral interstitial infiltration with blunt costophrenic angles and increased cardiothoracic ratio. One of his 2 blood cultures grew round budding yeasts on the fourth day after blood collection, which were identified as C. neoformans. Serum cryptococcal antigen was positive at a titer of 1:2. Lumbar puncture was attempted; however, no cerebrospinal fluid was collected. On the admission date, the patient was empirically treated with intravenous ceftazidime and azithromycin. Following the blood culture result, intravenous amphotericin B deoxycholate 50 mg/day (0.87 mg/kg/day) and oral fluconazole 800 mg/day were added. The patient was improved. Subsequently, the patient developed acute kidney injury (AKI) and the antifungal agent was changed to liposomal amphotericin B 180 mg (3 mg/kg/day). The patient received induction therapy with 28 days of intravenous amphotericin B plus fluconazole 800 mg/day, followed by oral fluconazole at the dose of 400 mg/day thereafter. However, ruxolitinib was still continued. After 1 month of hospitalization and antifungal treatment, the patient developed new onset of fever and worsening of the lesion on his left leg. Intravenous vancomycin was initiated for empirical treatment of suspected nosocomial skin and soft tissue infection. Skin biopsy at the left leg lesion was performed. The tissue pathology showed suppurative granuloma involving dermis and subcutis that suggested mycobacterial skin and soft tissue infection, and Ziehl-Neelsen staining demonstrated numerous acid-fast bacilli. Tissue mycobacterial culture revealed positive organisms from acid-fast stain, and isolate identification by INNO-LiPA assay technique from liquid medium was compatible with M. haemophilum. The mycobacterium colony grew on chocolate plate agar after 42 days of incubation, but failed to grow on solid (Lowenstein-Jensen) medium. The patient was treated with levofloxacin 750 mg/day, rifampicin 300 mg/day, and ethambutol 800 mg/day; however, the patient was not improved after 7 days of antimicrobial treatment. He then developed septic shock and expired on the 48th day of hospitalization.