Prolonged granulocytopenia: the major risk factor for invasive pulmonary aspergillosis in patients with acute leukemia

Antibiotic regimen as an independent risk factor for disseminated fungal infections in neutropenic patients in Brazil

In a cohort of 79 febrile episodes in 50 consecutive neutropenic patients seen at the University Hospital, Federal University of Rio de Janeiro, Brazil, between 1987 and 1991, it was observed that the cumulative incidence of disseminated fungal infections rose from 3% to 19% after the introduction of a new empirical antibiotic regimen. In order to identify risk factors, as well as to assess the impact of the new antibiotic regimen on the emergence of fungal infections, a nested case-control study was undertaken, in which 10 cases of disseminated fungal infections were compared with 30 randomly chosen controls, drawn from the same cohort. In a multiple logistic regression analysis, the predictive factors for disseminated fungal infection were younger age (odds ratio 0.85, 95% confidence interval 0.75-0.97) and use of the new antibiotic regimen (odds ratio 14.18, 95% confidence interval 1.05-191.80) The probable explanation for the emergence of fungal infections is that the new antibiotic regimen, by lowering the incidence of bacteraemia-related deaths, allowed patients to be at risk for the development of disseminated fungal infections.

Infections in neutropenic patients I: aetiology

Improvement in supportive care including the introduction of new antibiotics, antiviral and antifungal agents and haematopoietic growth factors have all contributed to a decreased chemotherapy-related mortality and morbidity in cancer patients. However, infections/septic shock during neutropenia still constitutes a major threat to these patients. Most patients develop fever during neutropenia and in 20-40% a manifest bacteremia is documented. In patients with prolonged neutropenia, the risk for fungal infections is increased. The spectrum of bacterial, fungal and viral infections in the neutropenic patient is reviewed.

Association therapy as a prognostic factor in deep fungal infection complicating oncohaematological diseases

A group of 31 oncohaemopathic patients (17 male, mean age 44 +/- 6 years), diagnosed as having primary deep fungal infection involving the lungs, were retrospectively evaluated. When infection was suspected on a clinical basis the major associated risks for death were the duration of bone marrow aplasia (12 +/- 7 versus 21 +/- 6 days, P < 0.001), increase in white blood cells and, in particular, prolonged granulocytopenia (11 +/- 5 versus 24 +/- 8 days, P < 0.001) when survivors were compared with patients, who died. Our therapeutic empirical approach was based on the association of i.v. amphotericin B, 1 mg kg-1 day-1, with oral 5-fluorocytosine (5-FC) 150 mg kg-1 day-1. Only 9 subjects received combination therapy for more than 7 days. For majority of them, oral 5-FC was interrupted because of altered compliance or sustained liver damage. A chi 2 test for independent parameters showed (P = 0.0021) a concentration of deaths among patients who received amphotericin B alone (15/22); none of the patients treated with amphotericin B + 5-FC (9 cases) died. Results generally suggest that a more favourable outcome was statistically associated with empirical antifungal combination therapy in deep fungal infection, although both treatment regimens showed effectiveness in terms of survival. Nevertheless the low 5-FC compliance and the small sample do not indicate the safe use of this drug in a large population.

Invasive pulmonary aspergillosis. MRI, CT, and plain radiographic findings and their contribution for early diagnosis

A prospective study was conducted in 38 patients with nodular lesions on plain chest radiographs and the clinical suspicion of invasive pulmonary aspergillosis (IPA) to assess the diagnostic accuracy of magnetic resonance imaging (MRI) and computed tomography (CT). For early diagnosis of IPA (clinical signs and symptoms < 10 days), CT scans with demonstration of the halo sign had a high sensitivity (16/22) and specificity (8/8). Magnetic resonance imaging performed at the same time revealed a relatively higher sensitivity (22/22), but a very poor specificity (0/8). Gadolinium-diethylene-triamine-pentaacetic acid (Gd-DTPA) enhanced images did not improve specificity. In the later course of infection (clinical signs and symptoms > 10 days), MRIs showed typical nodular target-like lesions with Gd-DTPA enhancement of the rim area that was not seen in the early course of the disease or in patients with Pseudomonas or staphylococcal infection. In conclusion, MRI findings are not as characteristic as the CT halo sign in diagnosing IPA in the early course of the disease, but the MRI target sign with Gd-DTPA enhancement of the rim area and the "reverse target" on T2-weighted images are strongly suggestive of IPA at a later stage of the disease.

Aspergillary bronchopneumonia: an unusual cause of atelectasis and asphyxia in a leukemic patient

A 22-year-old man in his first relapse of T-acute lymphoblastic leukemia developed fever and a pulmonary infiltrate after 23 days of granulocytopenia. Although having been under amphotericin B for 10 days, productive purulent cough ensued, with right lobe atelectasis and acute ventilatory failure that resolved after the elimination of a thick gelatinous bronchial plug. Sputum cultures yielded Candida Albicans and Staphylococcus epidermidis, and microscopic examination of the sputum plug disclosed Aspergillus hyphae. The patient died 9 days after, of a disseminated Aspergillus infection, confirmed by necropsy.

A case of histiocytic medullary reticulosis complicated with x-ray-irradiated oral cancer

We report the case of a patient in whom oral squamous cell carcinoma and a fatal reactive form of histiocytosis were simultaneously manifested. Our conclusions indicate that such a hematophagocytic syndrome may occur in the setting of oral squamous cell carcinoma as previously described in other malignancies.

Fungal pneumonia

Fungal pneumonias are rare but important. Sometimes the clinical presentation is identical to more common bacterial or atypical pneumonias. In such cases, the diagnosis is either not made or is made accidentally from diagnostic specimens obtained to determine the likely bacterial pathogen. Other cases look like routine bacterial or atypical pneumonia at presentation but do not improve or even progress as they are being treated with appropriate antibacterial agents. In such cases, it is important not to give a series of treatment courses with different antibacterial antibiotics that all cover essentially the same range of pathogens. Rather the diagnostic efforts must be escalated, progressing to more aggressive measures (fiberoptic bronchoscopy, fine needle aspiration, and rarely thoracoscopic or traditional open lung biopsy) until a specific diagnosis is reached. In some cases, there are clinical clues that point to a fungal cause. Attention to these clues can lead to early initiation of appropriate diagnostic sequences, faster diagnosis, and earlier initiation of specific therapy. A review of some of these clinical clues is provided in Table 1.

Chemoprophylaxis of fungal infections in neutropenic patients

BACKGROUND

In recent years there has been an increasing incidence and awareness of mucosal candidiasis and invasive fungal infections in neutropenic patients. Early diagnosis (before serious morbidity and mortality) is often difficult, emphasizing the continuing need for adequate prophylaxis.

DESIGN

A review of studies on the chemoprophylaxis of fungal infections in neutropenic patients.

RESULTS

There is a limited number of large, prospective, well-designed studies using proper criteria and end points. No antifungal drug or drug combination has been shown to prevent invasive fungal infection with the exception of fluconazole (mainly Candida Albicans infections) in certain high-risk patients groups.

CONCLUSIONS

Prophylaxis strategies are dependent upon local conditions, patient populations, types of therapies, available resources, etc. Future improvement will be based upon a) improved study quality, b) new strategies for established drugs, c) development of new and safer drugs, d) new strategies to eliminate or reduce immunosuppression and e) cost-benefit studies.

Pulmonary fungal infections in immunocompromised patients: incidence and risk factors

In a prospective study, 178 patients with fever > 38.4 degrees C and newly diagnosed pulmonary infiltrates underwent bronchoscopy with bronchoalveolar lavage (BAL), aspiration of bronchial secretions (BS) and, in 71 cases, protected specimen brushing (PSB). In 42/143 immunocompromised patients (haematological malignancies, n = 92; AIDS, n = 22; immunosuppressant therapy, n = 29) and in 4/35 patients with no defined underlying disease fungal pneumonia was present (candidosis, n = 35; aspergillosis, n = 8 mixed fungal infection, n = 3). Candidosis was combined, in 17 cases, with Aspergillus (n = 3), bacterial (n = 15) or cytomegalovirus (n = 2) infection. Aspergillosis was combined in eight cases with infection with Candida (n = 3), Pneumocystis carinii (n = 1) or bacteria (n = 5). The sensitivity of BAL and PSB in Candida pneumonia was 48% and 50%, respectively; specificity was 75% and 74% respectively. Bronchial secretions were more sensitive in detecting Candida pneumonia, but specificity was only 55%. In aspergillosis, the specificity of BAL, BS and PSB in each case was 100%; the sensitivity of BAL, BS and PSB was 38%, 64% and 100%. Twenty-four fungal infections were fatal. Unfavourable prognostic factors were respiratory failure needing mechanical ventilation, diffuse bilateral pulmonary infiltrates, mixed fungal infections and start of i.v. antifungal treatment > 14 days after fever onset, which were associated with a mortality rate of 74%, 67%, 67% and 63% respectively.

Invasive pulmonary aspergillosis: a rare presentation of non-Hodgkin's lymphoma

We describe a patient with rapidly progressive pneumonia and a high level of serum lactate dehydrogenase, in whom postmortem study revealed the presence of a diffuse, small and large-cell multicentric non-Hodgkin's lymphoma, together with an invasive pulmonary aspergillosis. Aspergillosis is rare as a presenting feature of a lymphoproliferative disease; only one previous case has been reported to the best of our knowledge. Invasive aspergillosis and lymphoma should be considered in patients presenting with pneumonia and high level of lactate dehydrogenase.

Liposomal amphotericin B in the treatment of fungal infections in neutropenic patients: a single-centre experience of 133 episodes in 116 patients

Liposomal amphotericin B (AmBisome) was used for suspected or confirmed fungal infection complicating 133 neutropenic episodes in 116 patients not tolerating, or not responding to, conventional amphotericin. Adverse effects were infrequent and no significant renal impairment resulted. Acute reactions occurred in five patients, reversible hepatic dysfunction in 23, and hypernatraemia in 17. The putative mycosis resolved with AmBisome treatment in 81 episodes (61%) and progressed with fatal outcome in 25 (19%), but the diagnosis was equivocal in most, and in 27 episodes (20%) evidence indicating nonfungal pathogenesis emerged. Treatment efficacy is, however, evaluable in those with proven aspergillosis. 13/17 patients with confirmed invasive aspergillosis responded to AmBisome (77%), conventional amphotericin having failed in 11. Treatment was successfully discontinued when the neutrophil count was < 1 x 10(9)/l in eight responders (61%). In four further patients treated for suspected aspergillosis, disseminated infection was documented at post-mortem, but the true incidence is unknown. This analysis confirms that AmBisome is well tolerated and effective against invasive mycoses in neutropenic patients, and may salvage patients when conventional amphotericin proves excessively toxic or ineffective.

Resection of chest wall and central veins for invasive cutaneous aspergillus infection in an immunocompromised patient

Primary cutaneous invasive Aspergillus infection at a Hickman catheter site led to chest wall involvement and central venous suppurative thrombophlebitis in a patient with relapsed acute myelogenous leukemia. Therapy included high-dose amphotericin B, serial wound debridements pending bone marrow recovery, and definitive resection of the infected chest wall and thrombosed internal jugular, subclavian, and innominate veins. To our knowledge, this procedure for control of invasive fungal infection has not been reported previously.

Invasive oral aspergillosis in immunocompromised patients with leukemia

The clinicopathologic characteristics of invasive oral aspergillosis in 16 immunocompromised patients who developed this infection during antileukemic chemotherapy are described. The primary site of the infection was the marginal gingiva, there was severe spontaneous pain, and the patients developed spiking fever and granulocytopenia. Necrotic ulceration of the gingiva rapidly extended to the contiguous mucosa, muscle, and bone. Microscopically, the necrotic tissue contained thrombotic vascular infarcts and there were hyphae that showed frequent transverse septa and dichotomous branching. The invasive organisms were not responsive to amphotericin B in the absence of remission of the leukemia and restoration of the depressed host defenses. In 15 patients who showed improvement of hematologic status, oral aspergillosis was controlled by the combination of antifungal chemotherapy and debridement of necrotic tissues.

Dose-dependent antifungal activity and nephrotoxicity of amphotericin B colloidal dispersion in experimental pulmonary aspergillosis

We investigated the safety and efficacy of amphotericin B colloidal dispersion (ABCD) for the treatment of invasive pulmonary aspergillosis in persistently granulocytopenic rabbits. Treatment groups included ABCD in dosages of 1, 5, and 10 mg/kg/day intravenously or conventional desoxycholate amphotericin B (DAmB) at 1 mg/kg/day intravenously. Antifungal activity was directly related to increasing dosage of ABCD as determined by the concentration of Aspergillus fumigatus organisms in lungs and the frequency of hemorrhagic pulmonary lesions. At 5 and 10 mg/kg/day, there was a significant reduction in the tissue burden of A. fumigatus as measured by percent culture-positive lobes and CFU per gram of tissue (P < or = 0.001), whereas at 1 mg/kg/day measured by percent culture-positive lobes and CFU per gram of tissue (P < or = 0.001), whereas at 1 mg/kg/day the tissue burden of A. fumigatus was not significantly different from that in untreated controls. Microbiological clearance was significantly greater at 1 mg of DAmB per kg per day than at 1 mg of ABCD per kg per day (P < or = 0.001). There was no difference in microbiological clearance of bronchoalveolar lavage fluid among the treatment groups as measured by CFU per milliliter. As determined by survival, ABCD at 5.0 mg/kg/day was more effective than DAmB at 1.0 mg/kg/day and ABCD at 10 mg/kg/day. ABCD at 10 mg/kg/day was more nephrotoxic than the lower dosages of ABCD and resulted in higher mortality. Impairment of glomerular filtration developed as a direct function increasing the ABCD dosage (r = 0.77; P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Use of amphotericin B aerosols for the prevention of pulmonary aspergillosis

Invasive pulmonary Aspergillus infections are increasingly recognized among severely neutropenic and/or immunosuppressed individuals. As the infections are usually acquired through the inhalation of Aspergillus conidia, at present prevention of invasive pulmonary aspergillosis consists mainly of the reduction of environmental exposure to aspergillus conidia. More recently, prophylaxis with amphotericin B aerosols has been investigated. Inhalations with amphotericin B aerosols significantly delayed mortality in an animal model of invasive pulmonary aspergillosis and high pulmonary concentrations of amphotericin B could be achieved. In man, pulmonary deposition of amphotericin B could also be demonstrated using commercially available nebulizers. Inhalations were well tolerated with little systemic absorption of the drug. In order to evaluate the efficacy of aerosol amphotericin B administrations for the prevention of invasive pulmonary aspergillosis, a prospective randomized trial has been initiated.

Amphotericin B versus amphotericin B plus 5-flucytosine: poor results in the treatment of proven systemic mycoses in neutropenic patients

Twenty-eight neutropenic (< 500 granulocytes/microliters) adults with microbiologically or histologically proven systemic mycosis were randomly assigned to receive either amphotericin B alone (0.5 mg/kg/day; n = 14) or amphotericin B (0.5 mg/kg/day) plus 5-flucytosine (150 mg/kg/day; n = 14) intravenously. Therapy was given for an average duration of 10 days in both groups, amounting to a total dose of amphotericin B of 338 mg and 308 mg, respectively. The mean duration of granulocytopenia was 18 days in the amphotericin B group and 20 days in the combination group. Only two patients treated with amphotericin B alone and three given the combination survived. Adverse events were similar in both groups with an elevation of the serum creatinine in six cases during the administration of amphotericin B alone and in seven cases treated with the combination. No other serious adverse events were encountered. Treatment with both regimens was disappointing partly because mycosis was too far advanced by the time therapy was begun and neutrophils were recovered in only half the patients.

Invasive cavitary pulmonary aspergillosis in patients with cancer: a clinicopathologic study

We studied the histopathology and clinicopathologic correlates of invasive cavitary pulmonary aspergillosis in 11 immunosuppressed patients with disseminated malignancy. In most patients cavities were produced by separation of necrotic from viable lung, resulting in an intracavitary sequestrum ("lung ball"). Central dissolution of large necrotic areas and suppurative granulomatous aspergillary pneumonia were additional causes of cavities in three patients. In four patients with chronic cavities sequestra had been replaced by intracavitary mycetomas ("fungus balls"). Neutrophils usually were numerous at the interface of the sequestrum and adjacent lung, but were minimally present in three patients with prolonged severe neutropenia. The lack of neutrophils in some patients suggests that factors other than neutrophil-derived proteases may be important in cavity formation. A prominent giant cell reaction was seen in three patients with chronic cavities. Hemoptysis occurred in five patients and massive hemoptysis due to a bronchoarterial fistula caused the death of one patient. The "air-crescent" sign was not observed radiographically in any patient and is therefore considered to be an insensitive marker for lung cavitation in invasive aspergillosis. Persistent intracavitary fungal growth may serve as a reservoir for recurrent fungal invasion in patients with prolonged or repeated episodes of severe neutropenia.

Disseminated aspergillosis in the acquired immunodeficiency syndrome

The relationship of disseminated aspergillosis with human immunodeficiency virus (HIV) infection is unclear. In the initial case definition of acquired immunodeficiency syndrome (AIDS) developed by the Centres for Disease Control (CDC), Atlanta, aspergillosis was included as an AIDS-defining opportunistic infection. In view of the primary relationship of aspergillosis with neutropenia rather than with lymphocyte depletion, as well as the lack of aspergillar infections among reported AIDS cases, aspergillosis was later deleted from the CDC case definition of AIDS. We describe a case of disseminated aspergillosis in a patient with AIDS, with an extensive literature review of the subject.

Invasive aspergillosis: clusters and sources?

Clusters of invasive infection with Aspergillus fumigatus are known to be associated with building works but studying the epidemiology has been hampered by the lack of a reliable typing system. A combination of three typing systems; silver staining of sodium dodecyl sulphate-polyacrylamide gels, immunoblot fingerprinting, and random amplification of polymorphic DNA (RAPD) was applied to seven cases on a haematology unit. The results show three of the patients to have indistinguishable isolates, suggesting a common source. Detection and removal of such sources, although difficult, would be an effective way of controlling the infection.

Pulmonary aspergillosis in patients with AIDS. Clinical and radiographic correlations

OBJECTIVE

To evaluate the clinical and radiographic features of pulmonary aspergillosis as they present in AIDS patients; in particular, to determine similarities and differences between Aspergillus infection in patients with AIDS vs those without AIDS.

SUBJECTS AND METHODS

Six new cases of confirmed or probable pulmonary aspergillosis were discovered during a search of hospital records. These are reviewed with 30 previously reported cases with special attention to radiographic appearance of disease and how radiographic appearance influences clinical outcome.

RESULTS

Symptoms of pulmonary aspergillosis in AIDS were nonspecific, most often including fever, cough, and dyspnea, and less commonly, chest pain or hemoptysis. Major risk factors for the development of pulmonary aspergillosis in patients with AIDS were steroid administration and neutropenia. Neutropenia was often a complication of therapies for AIDS, in particular, ganciclovir and zidovudine. Radiographic appearance of disease could be divided into three general categories. One third of the patients (13/36) presented with cavitary upper lobe disease resembling noninvasive or chronic necrotizing aspergillosis. Fatal hemoptysis occurred in 42 percent of patients with this form of disease. Twenty-two percent (8/36) of the cases presented as a nondescript focal alveolar opacity similar to invasive aspergillosis. In several patients, the focal infiltrate remained stable for several months, a feature that is unusual for aspergillosis in non-AIDS patients. The air crescent sign was present in none of the 36 reported cases. Patients with only focal disease had the best prognosis of patients with pulmonary aspergillosis. Bilateral alveolar or interstitial disease similar to invasive aspergillosis was present in 23 percent (9/36) of the patients. Bilateral disease appears to be a marker for disseminated infection and was associated with a high mortality due to aspergillosis. Two new forms of bronchial aspergillosis (5/36 cases) have been described previously. These patients presented with either obstructing fungal casts or bronchial pseudomembranes demonstrated bronchoscopically. In some patients with the bronchial forms of aspergillosis, transient alveolar opacities were seen on chest radiographs. These opacities may represent regions of atelectasis due to airway obstruction. One patient who had bilateral pneumothoraces without parenchymal opacities did not correspond to any of the three previously mentioned categories. Mortality due to aspergillosis was greater than 50 percent among AIDS patients. Death was subsequent to fatal hemoptysis or widespread pulmonary or systemic infection.

CONCLUSION

Unlike other risk groups that tend to contract only one form of pulmonary aspergillosis, AIDS patients can develop the whole spectrum of aspergillosis-related pulmonary disorders, including chronic cavitary, invasive, and bronchial forms of aspergillosis. Clinical symptoms are nonspecific and major risk factors include neutropenia, which is often a side effect of various therapies for AIDS, and steroid administration. Patients with the chronic cavitary form of disease have an unusually high mortality due to fatal hemoptysis. Patients with bilateral pulmonary infiltrates and aspergillosis have a high mortality due to disseminated infection.

Localized invasive pulmonary aspergillosis in patients with neutropenia. Effectiveness of surgical resection

BACKGROUND

Invasive pulmonary aspergillosis (IPA) is a major cause of morbidity and mortality in patients with neutropenia. Two severe complications with poor outcome can be observed after apparently successful IPA medical treatment: severe hemoptysis and IPA relapse during subsequent cytotoxic treatments. Early surgical therapy has not been considered routinely in the management of localized IPA.

METHODS

Six consecutive patients (four women, two men; median age, 52 years) with localized cavitating IPA diagnosed during chemotherapy-induced aplasia were treated with early surgical resection after hematologic recovery.

RESULTS

All patients received a lobectomy. Surgery was uneventful. This procedures allows patients to proceed with further intensive chemotherapy and/or bone marrow transplantation without IPA reactivation.

CONCLUSIONS

For selected patients, surgical resection of localized IPA with unique cavitating lesion, which prevents hemoptysis and IPA recurrence and allows for subsequent cytotoxic treatment, may be recommended.

Empiric amphotericin B therapy: the need for a reappraisal

Neutropenic patients are at high risk of developing invasive fungal diseases. A number of studies, both randomized and historical, have demonstrated that empiric therapy with amphotericin B in neutropenic patients with fever, refractory to antibiotics, results in a decrease in the frequency and mortality of deep fungal infections. Recent years have seen a number of advances in the management of neutropenic patients. Reasonably effective antifungal prophylaxis now exists and in many centres forms part of the routine care of neutropenic patients. Other centres advocate the use of selective decontamination and/or protective isolation. Furthermore the duration of neutropenia can be reduced with the use of haematopoetic growth factors. The impact of empiric amphotericin B in patients already benefiting from such treatments has not been adequately studied. The optimum dose of empiric amphotericin B is not defined. The criteria for commencing amphotericin B therapy in febrile neutropenic patients must therefore be redefined on the basis of further studies carried out in the context of these developments. We offer an approach to the use of empiric amphotericin B based on risk factors and prophylaxis.

Recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) after chemotherapy in patients with non-Hodgkin's lymphoma; a placebo-controlled double blind phase III trial

To assess the clinical and hematopoietic effects of rhGM-CSF, a placebo-controlled double blind multicenter phase III study was undertaken in patients with non-Hodgkin's lymphoma receiving cytotoxic chemotherapy. Sixty-two patients who had granulocytopenia (< 1 x 10(3)/microliters) after the first cycle of chemotherapy with cyclophosphamide, adriamycin, vincristine, and prednisolone were enrolled. After the second cycle of chemotherapy with the same regimen, patients randomly received either rhGM-CSF (125 micrograms/m2/day) or placebo for 14 days (rhGM-CSF; 31 patients and placebo; 31 patients). Administration of rhGM-CSF induced a significant increase in granulocytes mainly with neutrophils, eosinophils and monocytes, but elevation of lymphocytes, platelets, and reticulocytes was not induced. Median days of granulocytes less than 1 x 10(3)/microliters in patients receiving rhGM-CSF were significantly shorter than in patients receiving placebo (p = 0.001). Adverse reactions encountered with rhGM-CSF, and observed in 58% of the patients were never life-threatening and always rapidly reversible. They included fever, nausea and vomiting, diarrhea, skin eruption, and malaise. These results suggest that rhGM-CSF can be safely administered to prevent neutropenia after chemotherapy in patients with non-Hodgkin's lymphoma.

Lethal infections in patients with hematological malignancies

The hospital files of 410 patients with hematological malignancy treated at our clinic between 1977 and 1990 were reviewed to determine the importance of infections as a cause of death. The total number of infections was 203 (49.5%). A microbiologically documented infection was detected in 27.3%, a clinically documented infection in 9.5% and a possible infection in 12.7% of the patients. Gram-positive bacteria were responsible for 25.9%, gram-negative bacteria for 31.3%, anaerobic bacteria for 2.7%, viruses for 4.5% and fungi for 25.9% of the microbiologically documented infections. Of 29 systemic fungal infections only 2 were diagnosed before the patients died. The remaining diagnoses rested on autopsy findings. Empiric antifungal therapy was introduced in 1983; still, 74.2% of systemic fungal infections in 1977-1990 were detected after 1982. Patients with a verified infection had statistically significantly higher CRP concentrations than patients who died of other causes (152 mg/l vs. 117.5 mg/l, p = 0.018). We conclude that infection is a significant cause of death in patients with these diseases. The number of systemic fungal infections is increasing, despite the widespread use of antifungal medication and thus better diagnostic methods and more effective treatment are needed.

Effect of transfer factor on myelosuppression and related morbidity induced by chemotherapy in acute leukaemias

The aim of this study is to determine the safety and efficacy of Transfer Factor (TF) in accelerating the haematopoietic recovery in patients with acute leukaemias (AL), following intensive therapy to induce remission of the disease. Twenty-two patients with different types of AL (16 AML, three BC-CML and three ALL) were studied. The patients were divided in two groups. Group 1 (eight AML, two BC-CML and one ALL) received, after myelosuppression induced by chemotherapy, TF (1 unit daily, subcutaneous) until leucocyte count was > 2.5 x 10(9)/l and platelet count > 80 x 10(9)/l. Group 2 was considered the control group and did not receive TF. Treatment with TF accelerated the recovery of neutrophils, leucocytes, platelets (P < 0.001) and haemoglobin (P < 0.01). As a logical consequence, incidence and severity of infection and haemorrhage were lesser in the TF group than in the control group. There was no evidence that TF accelerated the re-growth of leukaemic cells. It seems that TF is safe in AL, accelerating haematopoietic recovery. However, it should be used with caution until results of additional trials become available.

Prognostic factors of invasive pulmonary aspergillosis in leukemic patients

The study objective was to identify prognostic factors associated with survival in patients treated for acute leukemias who developed invasive aspergillosis (IA) during induction therapy. This retrospective analysis involved 21 patients treated in two hematologic centers over a six-year period. All were treated in protective isolated rooms with high-dose amphotericin B as soon as fungal infection was suspected. Ten (45%) of the twenty-one patients died. There was no statistical difference between the patients who survived and those who died in relation to the mean time of onset of IA or the total and mean daily dose of amphotericin B. On the other hand a favourable outcome correlated strongly with complete leukemic remission (p < 0.0001): all but one of the patients with objective residual leukemia died of IA, whereas all those who achieved complete hematological remission survived. In conclusion, it seems that the main vital prognostic factor in these leukemic patients with IA was the achievement of complete remission. We were unable to control IA in 10 of 11 patients with refractory leukemia, regardless of neutropenic status, despite early administration of high-dose amphotericin B. All the patients who achieved complete remission were successfully treated with amphotericin B.

The alkaline protease of Aspergillus fumigatus is not a virulence determinant in two murine models of invasive pulmonary aspergillosis

Little is known of the pathophysiology of invasive pulmonary aspergillosis (IPA), an opportunistic fungal infection usually caused by Aspergillus fumigatus. It has been suggested that the ability of the fungus to degrade elastin may aid its invasion and growth in lung tissue. We have described previously the construction of a strain of A. fumigatus in which the gene encoding an alkaline protease, AFAlp, had been disrupted (C.M. Tang, J. Cohen, and D.W. Holden, Mol. Microbiol. 6:1663-1671, 1992); this mutant is deficient in extracellular proteolytic and elastinolytic activity over a broad pH range. In this study, we compared the pathogenicity of this and another AFAlp disruptant with their isogenic, elastase-producing parental strains in two murine models of IPA. In both models, animals were inoculated via the respiratory tract. In the first model, the inoculum was delivered as airborne conidia and animals developed signs of respiratory distress within 2 to 4 days. In the second model, conidia were administered intranasally as a suspension and the disease developed over a 2-week period. No difference was observed between the wild-type and AFAlp disruptants in terms of mortality, and elastin breakdown was detected in lung tissue from animals inoculated with all four strains. We conclude that AFAlp is not a virulence determinant in these models of IPA.

Invasive aspergillosis in leukemic children

Two cases of invasive aspergillosis are reported. Case 1, a 3-year-old boy with leukemic transformation of myelodysplastic syndrome, had an aspergillus infection in the hand, resulting in necrosis of the thumb. Case 2, an 18-year-old girl with acute megakaryoblastic leukemia, had an aspergillus skin infection on the wrist, accompanied by swelling and discoloration of the arm. In Case 2, angiography revealed a hypovascular lesion and vascular irregularity, suggesting that vessels were involved. Intraarterial infusion of urokinase and amphotericin B led to improvement of these symptoms in this patient. The combination of urokinase and an antifungal drug should be considered for intractable aspergillus infections involving the extremities.

Recurrent Pseudallescheria boydii sinusitis in acute leukemia

Most episodes of fungal sinusitis in immunocompromised patients are caused by Aspergillus species. To treat such infections, surgical debridement and anti-fungal therapy have been recommended; it is also clear however that an adequate neutrophil count is important in controlling such infections. We report a case in which fungal sinusitis was shown to be due to P. boydii and in which the infection recurred over a period of 2 years during episodes of neutropenia in spite of vigorous surgical and medical therapy.

Factors associated with invasive lung aspergillosis and the significance of positive Aspergillus culture after liver transplantation

From January 1981 to December 1990, 2180 patients underwent orthotopic liver transplantation at the University of Pittsburgh. Thirty-two patients (1.5%) were identified with invasive aspergillosis (29 lung, 2 intraabdominal, 1 meningitis). Of 29 patients with invasive lung disease, only 23 (79%) had positive culture (Aspergillus fumigatus, 20; Aspergillus flavus, 3). Forty-eight variables were analyzed and compared in 23 patients with invasive disease with positive cultures and 9 patients with colonization only. The variables associated with pulmonary invasive disease, by univariate analysis, were surgical time (P = .03), presence of laparotomies (P = .02), higher creatinine level at time of Aspergillus isolation (P = .01), and use of OKT3 (P = .02). However, in a multivariate analysis, only the last two (creatinine, OKT3) were associated with invasive lung aspergillosis. Of 4 patients with positive abdominal wound culture, 2 had local invasive aspergillosis. Therefore, positive cultures of Aspergillus organisms from respiratory secretions and wound drainage may represent invasive disease and should not be ignored.

Activity of MS-8209, a nonester amphotericin B derivative, in treatment of experimental systemic mycoses

The in vitro and in vivo toxicities and activities of MS-8209, a new hydrosoluble amphotericin B (deoxycholate-amphotericin B [D-AmB]; Fungizone) derivative, were studied. In vitro, MS-8209 was less toxic than AmB against renal tubular cells in primary culture and less active against Candida albicans and Cryptococcus neoformans. However, at 10-fold the AmB concentration, MS-8209 in vitro antifungal activity paralleled that of AmB. Fifty-percent lethal doses of MS-8209 and D-AmB in OF1 noninfected mice were 26 and 2.3 mg/kg, respectively. Therapeutic efficacy of MS-8209 was assessed in murine candidiasis, cryptococcosis, and aspergillosis. In each model of infection, we determined the maximum tolerated dosages of MS-8209 and D-AmB, i.e., the dosage inducing less than 15% mortality due to toxicity; the efficacies of MS-8209 and D-AmB at their respective maximum tolerated dosages were compared. In candidiasis, MS-8209 (15 mg/kg) significantly increased the survival time compared with D-AmB (0.5 mg/kg). Both compounds were equally effective at reducing CFU counts in the kidney. MS-8209 was the most effective agent for increasing the survival time in cryptococcal meningoencephalitis and for reducing CFU counts in spleen, brain, and lung during both cryptococcal pneumonia and meningoencephalitis. In aspergillosis, MS-8209 and D-AmB similarly prolonged the survival of treated mice compared with controls. These results show that when MS-8209 and D-AmB were used at the maximum tolerated dosage, MS-8209 was as effective as or more effective than D-AmB for the treatment of systemic mycoses. These findings warrant further experiments to study the pharmacokinetic properties and toxicity of MS-8209 under conditions of chronic administration.

Invasive aspergillosis complicating induction chemotherapy of childhood leukaemia

Two children with acute leukaemia developed histologically confirmed invasive aspergillosis within 2 weeks after onset of polychemotherapy. One child had received only prednisone and one pulse of vincristine and daunorubicin before. This child showed classical roentgenographic signs of aspergilloma following an upper pulmonary lobe infiltration. The second patient developed caecal aspergillosis obscured by clinical signs of appendicitis. He died of disseminated aspergillosis several weeks later in spite of systemic antifungal therapy. Both case reports illustrate that the possibility of invasive aspergillosis must also be expected in young patients soon after onset of induction chemotherapy.

Cerebral infection complicating systemic aspergillosis in acute leukemia: clinical and radiographic presentation

Cerebral fungal infection is becoming an increasingly recognized entity in immunocompromised patients on post-mortem examination. In order to determine the frequency of clinically significant cerebral fungal infection and define its clinical characteristics in a cohort of immunocompromised patients at high risk of fungal infection, the records of 118 patients with acute leukemia were examined for 57 clinical and laboratory features. The characteristics of 26 patients with systemic aspergillosis and acute leukemia were compared to 92 patients with acute leukemia in a control group. Eight of 118 patients (7%) had cerebral infection (seven Aspergillus, on Candida). Patients with systemic aspergillosis were more likely than patients in the control group to have focal neurologic findings (p = 0.02), confusion (p = 0.04), and abnormal computerized tomography (CT) of the brain characterized by single or multiple, enhancing or non-enhancing hypodense lesions (p = 0.02). Patients with systemic aspergillosis were more likely to die in complete remission than patients in the control group (p = 0.003); three of six patients with aspergillosis who died in remission expired as a consequence of cerebral infection. Cerebral infection complicated systemic Aspergillus infection in seven of 26 patients (27%), versus one of 16 patients with systemic Candida infection (6%) (p = NS). The authors conclude, therefore, that systemic aspergillosis complicating acute leukemia is more likely to be associated with confusion, focal neurologic findings, and abnormal CT scan of the brain, and that these findings suggest the presence of cerebral infection. In addition, cerebral infection commonly complicates the course of systemic aspergillosis, and is a significant cause of morbidity and mortality in patients with acute leukemia. A high index of suspicion is needed to insure early diagnosis and appropriate therapy, particularly in those who achieve remission of their leukemia.

Specific binding of human fibrinogen fragment D to Aspergillus fumigatus conidia

The interaction of purified human fibrinogen with Aspergillus fumigatus conidia was investigated by immunofluorescence and electron microscopy and binding assays with radiolabeled proteins. We described the localization of the binding sites on the A. fumigatus conidia and on the fibrinogen molecule and determined the binding characteristics. Immunofluorescence revealed that the fixation of purified fibrinogen was selectively associated with conidia and suggested a role for the D domains of the fibrinogen molecule. Binding assays performed with 125I-radiolabeled proteins confirmed that binding sites were located specifically in the D domains. No reaction could be detected with fragment E. The binding of 125I-fragment D to conidia was time dependent, saturable, and specific. Scatchard analysis of the data revealed an average of 1,200 binding sites per conidium, and an apparent dissociation constant (Kd) of 2.2 x 10(-9) M was estimated. Pretreatment of the cells with proteolytic enzymes or heat abolished binding, demonstrating the protein nature of the binding sites. Ultrastructural localization of the fungal receptors was determined by transmission electron microscopy. Labeling appeared to be associated with the outer electron-dense layer of the conidial wall and progressively decreased during the germination process. Labeling of thin sections with fragment D and an antifibrinogen immune serum revealed that binding sites also lay in the inner part of the wall and in vacuoles. These results indicate the presence at the conidial surface of specific receptors for fibrinogen which could act as mediators of conidial adherence to host tissues.