Mucormycosis-associated fungal infections in patients with haematologic malignancies

Among patients with haematologic disorders, mucormycosis most commonly occurs in those with acute leukaemia or lymphoma who have developed neutropenia due to malignancy or to chemotherapy, and in transplanted patients receiving immunosuppressive treatment. Here, we aim to present a retrospective study conducted over a 5-year period (2001-2005). The study included 20 patients with haematologic malignancies with a proven mucormycosis admitted in Medical Oncology Divisions in Cukurova University Hospital. The most frequent sites of infection were paranasal sinuses (95%) and lung (5%). Antifungal treatment was empirically administered in 18 (90%) patients; 18 patients underwent radical surgical debridement (90%). The therapy was successful for only eight patients (40%). Eleven patients died within 1 months of the diagnosis of fungal infection: the cause of death was only by mucormycosis in four patients (36.6%), mucormucosis and systematic inflamatuar response syndrome (SIRS) in two patients (18.2%) and progression of haematologic disease in five patients (45.5%). At univariate analysis, the factors that correlated with a positive outcome from infection were the following: amphotericin B treatment, neutrophil recovery from postchemotherapy aplasia. At multivariate analysis, the factors that significantly correlated with recovery from infection were the liposomal amphotericin B treatment (p = 0.026), doses of L-AmB (p = 0.008) and the length of the treatment (p = 0.01), respectively. It seems to have increased in recent years. Although a reduction of mortality has been observed recently, the mortality rate still remains high. Extensive and aggressive diagnostic and therapeutic procedures are essential to improve the prognosis in these patients.

[Invasive pulmonary mucormycosis with invasion of the thoracic spine in a patient with myelodysplastic syndrome]

We report the case of a 67-year-old patient who presented with a myelodysplastic syndrome and who developed a pulmonary mucormycosis with a rare extension to the dorsal spine. A decompressive laminectomy was attempted after failure of broad-spectrum antifungal treatment (Cancidas, V-Fend). The diagnosis was obtained after surgical biopsy. The scheduled lobectomy could not be performed because of altered clinical condition. The patient eventually died despite adapted antifungal treatment (Abelcet, Posaconazole). Pulmonary mucormycosis is a rare cause of mycotic infection that reaches most of the time immunocompromised patients. The pathogenic agent is part of zygomyces that have angio-invasive ability. Perineural propagation was recently described. Immunodepression, late diagnosis and lack of response to new generation antifungal drugs (V-Fend, Cancidas) are responsible for therapeutic failure in this disease. This case emphasizes the risk inherent to empirical antifungal treatment and the need of early biopsy in cases that do not respond to treatment.

Aspergillus/allergic bronchopulmonary aspergillosis in an Irish cystic fibrosis population: a diagnostically challenging entity

BACKGROUND

Patients with cystic fibrosis (CF) can become colonized by aspergillus, which can act as an allergen and cause allergic bronchopulmonary aspergillosis (ABPA).

OBJECTIVE

To determine the rate of aspergillus colonization and ABPA in a population of Irish patients with CF.

METHODS

In 50 consecutive patients with CF who presented with exacerbations, we looked for the presence of aspergillus in their sputum and signs and symptoms of ABPA.

RESULTS

Fifteen patients (30%) grew aspergillus species in their sputum cultures. Six patients (12%) had ABPA. Matched for age, sex, genotype, and microbiology, there was no significant difference in forced expiratory volume in the first second (percent predicted, FEV(1)%) in subjects with aspergillus-positive sputum compared to those not colonized with aspergillus. Subjects with ABPA experienced sharp short-term deterioration in lung function (mean 6.7% predicted FEV(1)), which returned to baseline following at least 4 weeks of treatment.

CONCLUSIONS

The prevalence of ABPA was 12%. Aspergillus-positive sputum of itself was not a poor prognostic sign in terms of lung function over the 5-year study course. ABPA produces short-term reversible declines in lung function and responds to treatment. The frequency of aspergillus isolates did not correlate with the occurrence of ABPA. A low threshold for the diagnosis of ABPA should be maintained in any patient with CF who does not improve with antibiotics.

An aspergilloma caused by Aspergillus flavus

Chronic pulmonary aspergillosis is broad term encompassing chronic cavitary, chronic fibrosing pulmonary aspergillosis and aspergilloma. All affect patients with structural lung diseases and many have subtle genetic immune defects. Almost all cases are caused by Aspergillus fumigatus. Here we report a patient with an aspergilloma which had Aspergillus flavus recovered from a surgical specimen and serum containing detectable precipitating antibody.

Bilateral pulmonary shadows and incapsulated mediastinal effusion in a patient with respiratory blastoschizomycosis

INTRODUCTION

Invasive blastoschizomycosis is an emerging and fatal infection of severely immunocompromised patients. Pneumonia caused by this fungus has been reported as a post mortem diagnosis in a patient with haematologic malignancy.

CASE REPORT

A 46-year-old unemployed Caucasian man, smoker, was admitted on emergency in a serious condition, with bilateral pulmonary infiltrates (chest x-ray) and incapsulated mediastinal pleural effusions (computed tomography scans). Blastoschizomyces capitatus (Trichosporon capitatum) has been isolated from two sputum samples and bronchial secretion aspirate obtained by bronchoscopy.

CONCLUSION

Pneumonia caused by Blastoschizomyces capitatus can develop in subjects without underlying malignancy but with history of heavy alcohol intake, tobacco smoking and malnutrition and may have favorable disease outcome.

[Retrospective analysis of three cases of pulmonary mucormycosis]

OBJECTIVE

To describe the clinical characteristics of pulmonary mucormycosis and to evaluate the approaches to its diagnosis and treatment.

METHODS

Three cases of pulmonary mucormycosis were successfully diagnosed by histopathologic examination of infected tissues obtained by fiberoptic bronchoscopy in this hospital. The clinical features of the cases were analyzed and the literature reviewed.

RESULTS

Three patients were all farmers and two of them had had diabetic ketoacidosis. The first patient died from massive hemoptysis one day after the diagnosis was confirmed. The second patient was cured by large doses of intravenous amphotericin B (total dosage 2 g). The third patient presented with right middle bronchial stenosis after right upper lobectomy because of squamous carcinoma, and was cured by amphotericin B (1.5 g) combined with interventional therapy under fiberoptic bronchoscopy. The two patients were followed for 0.5 - 1 year without relapse.

CONCLUSIONS

The mortality of pulmonary mucormycosis is high. Fiberoptic bronchoscopy is a useful diagnostic method for histopathologic examination. Successful treatment of pulmonary mucormycosis includes early diagnosis, control of underlying diseases and surgical intervention of isolated lesions combined with large dosage of amphotericin B.

Implantable cardioverter-defibrillator infection due to Scedosporium apiospermum

We report a case of implantable cardioverter-defibrillator infection due to Scedosporium apiospermum. This infection persisted despite systemic antifungal treatment with voriconazole and was controlled after removal of the foreign device and replacement of the involved tricuspid valve. This case underscores the importance of a combined surgical and medical approach for this complicated infection. Scedosporium species should be considered in the differential diagnosis of cardiac or intravascular device-related infections.

[Case of pulmonary pseudallescheriasis responding successfully to treatment with voriconazole]

A 27-year-old man was admitted with hemoptysis in October 2005. Chest radiograph and CT showed multiple nodules forming a large mass in the left upper lobe. We suspected pulmonary aspergillosis because we detected filamentous fungi made of chains of cells in the bronchial washing fluid. On October 6, therapy with micafungin was initiated. Despite this intervention, the patient's clinical status worsened. On Octorber 11, we suspected pulmonary pseudallescheriasis because we detected colonis resembling white down in Sabouraud agar, thus mica-fungin was discontinued due to the lack of response and we began treatment with voriconazole. The patient's clinical status subsequently improved. We performed a left upper lobectomy, because residual the shadows were recognized on chest CT. Here we report a rare case of pulmonary pseudallescheriasis successfully treated with voriconazole and left upper lobectomy.

Isolation of the right upper-lobe with a left-sided double-lumen tube after left-pneumonectomy

A patient with a prior left pneumonectomy required surgical drainage of a right upper lobe aspergilloma. A left double-lumen endobronchial tube was placed in the right bronchus intermedius, isolating the right upper lobe while allowing ventilation of the right middle and lower lobes.

Coccidioidomycosis pneumonia in a nonendemic area associated with infliximab

Tumor necrosis factor (TNF) inhibitors, such as infliximab, are highly effective in the management of rheumatoid arthritis; however, these agents are associated with an increased risk of infectious complications. Individuals developing coccidiomycosis pneumonia frequently acquire this while residing in endemic regions. We present a patient with rheumatoid arthritis treated with infliximab who developed acute respiratory distress syndrome (ARDS) from coccidiomycosis pneumonia while residing in a non-endemic region near the Texas-Louisiana border and was successfully treated with antifungal therapy. The source for coccidiomycosis was suspected to be from inhalation of pulverized rock dust imported from Arizona. Patients treated with TNF inhibitors may acquire coccidiomycosis infection through fomite dust exposure.

[Bronchopulmonary aspergillosis infections in the non-immunocompromised patient]

The definition of broncho-pulmonary aspergillosis infections in non-immunocompromised patients remains vague and a wide range of clinical, radiological and pathological entities have been described with a variety of names, i.e. simple aspergilloma, complex aspergilloma, semi-invasive aspergillosis, chronic necrotizing pulmonary aspergillosis, chronic cavitary and fibrosing pulmonary and pleural aspergillosis, pseudomembranous tracheobronchitis caused by Aspergillus, and invasive aspergillosis. However, these disease entities share common characteristics suggesting that they belong to the same group of pulmonary aspergillosis infectious disorders: 1- a specific diathesis responsible for the deterioration in local or systemic defenses against infection (alcohol, tobacco abuse, or diabetes); 2- an underlying bronchopulmonary disease responsible or not for the presence of a residual pleural or bronchopulmonary cavity (active tuberculosis or tuberculosis sequelae, bronchial dilatation, sarcoidosis, COPD); 3- generally, the prolonged use of low-dose oral or inhaled corticosteroids and 4- little or no vascular invasion, a granulomatous reaction and a low tendency for metastasis. There are no established treatment guidelines for broncho-pulmonary aspergillosis infection in non-immunocompromised patients, except for invasive aspergillosis. Bronchial artery embolization may stop hemoptysis in certain cases. Surgery is generally impossible because of impaired respiratory function or the severity of the comorbidity and when it is possible morbidity and mortality are very high. Numerous clinical cases and short retrospective series have reported the effect over time of the various antifungal agents available. Oral triazoles, i.e. itraconazole, and in particular voriconazole, appear to provide suitable treatment for broncho-pulmonary aspergillosis infections in non-immunocompromised patients.

Fungal infections in solid organ transplantation

Fungal infections in solid organ transplant recipients continue to be a significant cause of morbidity and mortality. Candida spp. and Aspergillus spp. account for most invasive fungal infections. The incidence of fungal infection varies with type of solid organ transplant. Liver transplant recipients have highest reported incidence of candida infections while lung transplant recipients have highest rate of Aspergillus infections. Recent epidemiological studies suggest the emergence of resistant strains of candida as well as mycelial fungi other than Aspergillus in these patients. The current review incorporates the recent changes in the epidemiology of fungal infections in solid organ transplant recipients and highlights the newer data on the diagnosis, prophylaxis and treatment of fungal infections in these patients.

Variable Number of Tandem Repeats of TNF Receptor Type 2 Promoter as Genetic Biomarker of Susceptibility to Develop Invasive Pulmonary Aspergillosis

Tumor necrosis factor alpha (TNF-alpha) and lymphotoxin alpha (LT-alpha) are pivotal mediators of inflammatory responses in fungal infection diseases. We hypothesized that polymorphisms in genes of these cytokines or their receptors might increase the susceptibility of hematologic patients to develop invasive pulmonary aspergillosis (IPA). One hundred two hematologic patients and 124 age-matched controls were enrolled in the study, and the following standard single nucleotide polymorphisms were investigated: TNF-alpha -308 and +489, LT-alpha +252 and Tumor Necrosis Factor Receptor 2 (TNFR2) +676. Variable number of tandem repeats (VNTRs) at position -322 of the TNFR2 gene were also studied. Genotypic and allelic frequencies were similar between patients and controls. IPA was diagnosed in 54 of the 102 patients according to consensus criteria published by the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group. TNF-alpha and LT-alpha polymorphisms were not associated with presence of IPA. Susceptibility to IPA was strongly associated with VNTR at position -322 in the promoter region of the TNR2 gene (p = 0.029) but was not associated with the presence of TNFR2 +676 polymorphism. A genetic difference in TNFR2 promoter VNTR may play a major role in susceptibility to IPA infection.

Acute respiratory distress syndrome due to chronic necrotizing pulmonary aspergillosis

This is the first case report of acute respiratory distress syndrome (ARDS) due to chronic necrotizing pulmonary aspergillosis (CNPA). This patient had pulmonary fibrosis of unknown etiology with a right upper bulla. The wall of the bulla became thicker with the surrounding lung infiltration and the patient suddenly developed severe respiratory failure. It is necessary to confirm the possibility that ARDS may occur in CNPA and that peripheral eosinophilia might forebode worsening of CNPA.

Lung mass caused by Phoma exigua

We describe a well documented case of a fatal Phoma exigua lung infection in a patient with acute myeloid leukaemia and diabetes. The infection was histology and culture proven and a PCR assay was developed for detecting P. exigua DNA in deparaffinized lung-biopsy material. Confirmation of rare fungal pathogen infections requires a multidisciplinary approach involving clinical observations, mycology, histopathology and radiology.

Concomitant invasive pulmonary aspergillosis and aspergillus sinusitis in a patient with acute leukaemia

A 67 years old male otherwise healthy who had undergone surgery for nasal polyposis ten years earlier was recently diagnosed with B-cell acute lymphoblastic leukaemia. During induction treatment the patient developed sino-pulmonary aspergillosis caused byAspergillus flavus. The patient developed severe reactions against amphotericin- B and thereafter Abelcet, whereas he tolerated treatment with AmBisome. Surgery of the nasal cavities was performed whereas surgery of the pulmonary infiltrates was not possible. During subsequent treatment for his leukaemia and long periods of neutropenia, the patient was on AmBisome treatment and there were no signs of progression of the Aspergillus infection. The antifungal treatment was considered to be successful. The patient was referred back to his local hospital and antifungal treatment was switched to oral itraconazole.

Transient overexpression of gamma interferon promotes Aspergillus clearance in invasive pulmonary aspergillosis

Cytokines are critical molecules necessary for normal lung pathogen host defences. Gamma interferon (IFN-gamma) and T1-phenotype immune responses are important components of host defence against Aspergillus. Therefore, we hypothesized that transient overexpression of IFN-gamma within the lung could augment host immunity against Aspergillus. Here it was showed that intranasal administration of 5 x 10(7) colony-forming units (CFU) of Aspergillus fumigatus (Af ) induced the expression of IFN-gamma. Mice were intranasally (i.n) administrated with 5 x 10(8) PFU of a recombinant adenovirus vector containing the murine IFN-gamma cDNA (AdmIFN-gamma), and challenged 24 h later with Af. We observed that i.n. administration of AdmIFN-gamma resulted in about a fourfold increase in levels of IFN-gamma and IL-12 within the lung, about a 75% reduction in lung fungal contents at day 2 and a more than threefold higher survival rate in the AdmIFN-gamma-treated group compared to the controls (P < 0.01). This protection effect was not found when AdmIFN-gamma was i.p. administrated. Alveolar macrophages and lung leucocytes isolated from i.n. AdmIFN-gamma-treated animals displayed enhanced killing of intracellular Aspergillus organisms ex vivo. These results demonstrate that transient overexpression of IFN-gamma could augment host defence against Aspergillus.

Invasive pulmonary aspergillosis in chronic obstructive pulmonary disease: an emerging fungal pathogen

Acute invasive pulmonary aspergillosis occurs predominantly in immunocompromised hosts, with increasing numbers of cases of invasive aspergillosis among patients with chronic obstructive pulmonary disease (COPD) being reported. Among 13 cases of invasive aspergillosis diagnosed in COPD patients admitted to the intensive care unit with acute respiratory distress, the only risk factor for invasive fungal infection was corticosteroid treatment. Invasive aspergillosis should be suspected in COPD patients receiving steroid treatment who have extensive pulmonary infiltrates. Survival depends on rapid diagnosis and early appropriate treatment. A decrease or interruption of steroid treatment should be considered as part of the overall therapeutic strategy.