Mucormycosis is an increasingly recognized invasive fungal infection (IFI) in patients with acute myeloid leukemia (AML) and after allogeneic (allo) stem cell transplantation (HSCT); it is mainly due to the severe and prolonged neutropenia related to high-dose chemotherapy. Here we report a case of 32-year-old AML who developed ten days after the onset of neutropenia during induction therapy, clinical and radiological findings of a possible IFI, such as a non productive cough, broad spectrum antibiotic resistant fever, prolonged neutropenia associated to a rapidly progressive peripheral pleural-based nodule with surrounding groundglass halo and a slight pleural effusion detected by high resolution computerized tomography (HRCT). During febrile neutropenia, serum aspergillus galactomannan (GM) antigens, tested twice a week, were not detected. Empirical treatment with liposomal amphotericin B (LamB, 3 mg/kg/day for 21 days) was started; three days later, fever disappeared concomitantly with the achievement of complete disease remission. Pulmonary HCRT scans sequentially performed 30, 37, and 45 days after starting induction chemotherapy showed at beginning an increase of nodular lesion (4.5 cm) and then a progressive infiltrate regression. At this time, a CT-guided fine needle biopsy of the pulmonary lesion and bronchoalveolar lavage (BAL) specimens, tested for aspergillus GM antigen, failed to document any fungal infection. As HRCT scan 45 days after first induction did not shown fully regression of lung nodule (2 cm), 7 days later, the patient underwent a limited toracothomy, leading to a complete surgical removal of the lung infiltrate. Fungal culture of lung specimens remained negative, but histological examination established a mucormycosis. Three weeks after surgery, the patient performed consolidation chemotherapy, and 98 days after first induction therapy, the patient received a myeloablative allo HSCT from a sibling HLA-matched related donor. Secondary prophylaxis with LamB, applied during both consolidation therapy and myeloablative sibling allo HSCT, was effective to prevent IFI recurrence despite the development of grade II acute graftversus- host disease (GVHD) and limited chronic GVHD requiring immunosuppressive treatment. Our case report further provide evidence that the combined surgical and LAmB therapy is an effective and safe choice for the management of pulmonary mucormycosis in hematological immunocompromised patients.

Combined liposomal amphotericin b and surgery as successful management for pulmunary mucormycosis in a patient with acute myeloid leukemia

Giudice V;SELLERI, Carmine
2013

Abstract

Mucormycosis is an increasingly recognized invasive fungal infection (IFI) in patients with acute myeloid leukemia (AML) and after allogeneic (allo) stem cell transplantation (HSCT); it is mainly due to the severe and prolonged neutropenia related to high-dose chemotherapy. Here we report a case of 32-year-old AML who developed ten days after the onset of neutropenia during induction therapy, clinical and radiological findings of a possible IFI, such as a non productive cough, broad spectrum antibiotic resistant fever, prolonged neutropenia associated to a rapidly progressive peripheral pleural-based nodule with surrounding groundglass halo and a slight pleural effusion detected by high resolution computerized tomography (HRCT). During febrile neutropenia, serum aspergillus galactomannan (GM) antigens, tested twice a week, were not detected. Empirical treatment with liposomal amphotericin B (LamB, 3 mg/kg/day for 21 days) was started; three days later, fever disappeared concomitantly with the achievement of complete disease remission. Pulmonary HCRT scans sequentially performed 30, 37, and 45 days after starting induction chemotherapy showed at beginning an increase of nodular lesion (4.5 cm) and then a progressive infiltrate regression. At this time, a CT-guided fine needle biopsy of the pulmonary lesion and bronchoalveolar lavage (BAL) specimens, tested for aspergillus GM antigen, failed to document any fungal infection. As HRCT scan 45 days after first induction did not shown fully regression of lung nodule (2 cm), 7 days later, the patient underwent a limited toracothomy, leading to a complete surgical removal of the lung infiltrate. Fungal culture of lung specimens remained negative, but histological examination established a mucormycosis. Three weeks after surgery, the patient performed consolidation chemotherapy, and 98 days after first induction therapy, the patient received a myeloablative allo HSCT from a sibling HLA-matched related donor. Secondary prophylaxis with LamB, applied during both consolidation therapy and myeloablative sibling allo HSCT, was effective to prevent IFI recurrence despite the development of grade II acute graftversus- host disease (GVHD) and limited chronic GVHD requiring immunosuppressive treatment. Our case report further provide evidence that the combined surgical and LAmB therapy is an effective and safe choice for the management of pulmonary mucormycosis in hematological immunocompromised patients.
File in questo prodotto:
Non ci sono file associati a questo prodotto.

I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.

Utilizza questo identificativo per citare o creare un link a questo documento: http://hdl.handle.net/11386/4238456
 Attenzione

Attenzione! I dati visualizzati non sono stati sottoposti a validazione da parte dell'ateneo

Citazioni
  • ???jsp.display-item.citation.pmc??? ND
  • Scopus ND
  • ???jsp.display-item.citation.isi??? ND
social impact