Three cases of infection with Fusarium species in neutropenic patients

The Impact of Corticosteroids on the Outcome of Fungal Disease: a Systematic Review and Meta-analysis

Purpose of Review

Corticosteroids have a complex relationship with fungal disease - risk for many, benefit for others. This systematic review aims to address the effect of corticosteroids on mortality and visual outcome in different fungal diseases.

Recent Findings

Corticosteroids are a risk factor of aspergillosis for patients who have COVID-19, and they also led to a worse outcome. Similarity, corticosteroids are a risk factor for candidemia and mucormycosis. Some researchers reported that using topical corticosteroid in keratitis was associated with worse visual outcome if fungal keratitis. Some studies showed that corticosteroids are linked to a negative outcome for non-HIV patients with Pneumocystis jirovecii pneumonia (PCP), in contrast to those with HIV and PCP.

Summary

In 59 references, we found that corticosteroid therapy showed a worse clinical outcome in invasive aspergillosis (IA) (HR: 2.50, 95%CI: 1.89-3.31, p < 0.001) and chronic pulmonary aspergillosis (CPA) (HR: 2.74, 95%CI: 1.48-5.06, p = 0.001), PCP without HIV infection (OR: 1.29, 95%CI: 1.09-1.53, p = 0.003), invasive candidiasis and candidaemia (OR: 2.13, 95%CI: 1.85-2.46, p < 0.001), mucormycosis (OR: 4.19, 95%CI: 1.74-10.05, p = 0.001) and early in the course of fungal keratitis (OR: 2.99, 95%CI: 1.14-7.84, p = 0.026). There was equivocal outcome in cryptococcal meningoencephalitis in AIDS and primary coccidioidomycosis, while corticosteroid therapy showed a better outcome in PCP in HIV-infected patients (RR: 0.62, 95%CI: 0.46-0.83, p=0.001) and fungal keratitis patients after keratoplasty surgery (OR: 0.01, 95%CI: 0.00-0.41, p = 0.041) and probably in cryptococcal meningoencephalitis in non-immunocompromised patients. A sub-analysis in invasive aspergillosis and CPA showed that use of more than 2 mg/kg/day of prednisolone equivalents per day is a significant factor in increasing mortality (HR: 2.94, 95%CI: 2.13-4.05, p < 0.001). Corticosteroid therapy during invasive fungal disease was usually associated with a slightly or greatly increased mortality or worse visual outcome (in fungal keratitis), with two disease exceptions. Avoiding the addition of corticosteroids, or minimising dose and duration in those who require them, is likely to improve the outcome of most life- and vision-threatening fungal diseases. This review provides a cornerstone for further research in exploring the accuracy of suitable dose and duration of corticosteroids treatment in fungal diseases.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12281-023-00456-2.

Epidemiology of infections in cancer patients

Although major advances in the care of cancer patients over the past several decades have resulted in improved survival, infectious complications remain a significant cause of morbidity and mortality. To successfully identify, treat, and prevent infections, a comprehensive understanding of risk factors that predispose to infection and of commonly encountered pathogens is necessary. In addition, clinicians must keep abreast of the changing epidemiology of infections in this population. As therapeutic modalities continue to evolve, as established pathogens become increasingly drug resistant, and as new pathogens are discovered, successful management of infections will continue to present challenges in the years to come.

Outcome predictors of 84 patients with hematologic malignancies and Fusarium infection

BACKGROUND

Invasive infection by Fusarium sp. is associated with high mortality in patients with hematologic cancer. Yet to the authors' knowledge, little is known regarding predictors of adverse outcome.

METHODS

The authors conducted a retrospective review of the records of patients with hematologic carcinoma and invasive fusariosis who were treated at one institution in the U.S. and at 11 centers in Brazil.

RESULTS

The records of 84 patients were evaluated. Neutropenia was present in 83% and 33 patients had undergone stem cell transplantation. Only 18 patients (21%) were alive 90 days after the diagnosis of fusariosis. Multivariate predictors of poor outcome were persistent neutropenia (hazard ratio [HR] of 5.43; 95% confidence interval [95% CI], 2.64-11.11) and use of corticosteroids (HR of 2.18; 95% CI, 1.98-3.96). The actuarial survival rate of patients without any of these factors was 67% compared with 30% for patients who recovered from neutropenia but were receiving corticosteroids and 4% for patients with persistent neutropenia only. None of the patients with both risk factors survived (P<0.0001).

CONCLUSIONS

Measures to reduce the duration of neutropenia, as well as the judicious use of corticosteroids, may reduce the high mortality rate of fusariosis in patients with hematologic cancer.

Cutaneous infection by Fusarium species in healthy and immunocompromised hosts: implications for diagnosis and management

Infections by Fusarium species frequently involve the skin, either as the primary or the metastatic site. To better understand the pathophysiology of these infections, 43 new patients with fusariosis were evaluated, and the literature was reviewed. A total of 259 patients (232 immunocompromised and 27 immunocompetent) were identified. Skin involvement was present in 70% of patients, particularly in immunocompromised patients (72% vs. 52%; P=.03). In immunocompetent patients, cutaneous infections were characterized by preceding skin breakdown, localized involvement, slow pace of progression, and good response to therapy. In contrast, skin involvement in immunocompromised patients was only occasionally preceded by skin breakdown and typically was presented as rapidly progressive disseminated lesions at various stages of evolution. Metastatic skin lesions were associated with fungemia, neutropenia, and death. Skin was the single source of diagnosis for the majority of immunocompromised and immunocompetent patients. Recommendations for the prevention of fatal fusariosis originating from skin are presented.

Epidemiology of infectious complications in cancer patients

Patients with underlying malignancies are at risk for a wide array of infectious diseases that cause significant morbidity and mortality. To develop a clear etiologic understanding of the infectious agents involved first requires a knowledge of the factors that predispose to infection. Neutropenia is clearly the single most important risk factor for infection in the cancer patient. However, a variety of both host and treatment-associated factors act together to predispose these patients to opportunistic infections. Approaching the individual malignancies with a knowledge of the underlying risk factors helps logically guide diagnosis and therapy. The astute clinician must also be aware of new and emerging infections in this patient population. As new pathogens are discovered and established pathogens become increasingly drug resistant, they will continue to present challenges for physicians caring for these patients in the years ahead.

Invasive infection with Fusarium chlamydosporum in a patient with aplastic anemia

We report the first case of invasive disease caused by Fusarium chlamydosporum. The patient had aplastic anemia with prolonged neutropenia and was treated with immunosuppressive therapy. While she was receiving empirical amphotericin B, a dark crusted lesion developed on her nasal turbinate. Histologic analysis revealed invasive hyaline hyphae and some darkly pigmented structures that resembled conidia of dematiaceous molds. Only after the mold was grown in culture were characteristic colonial morphology, phialides, conidia, and chlamydospores evident, thus permitting the identification of F. chlamydosporum. This case illustrates the ever-increasing spectrum of pathogenic Fusarium spp. in immunocompromised patients and emphasizes the potential pitfalls in histologic diagnosis, which may have important treatment implications.

Fusarium, a Significant Emerging Pathogen in Patients With Hematologic Malignancy: Ten Years' Experience at a Cancer Center and Implications for Management

Despite increasing reports of life-threatening Fusarium infections, little is known about its pathogenesis and management. To evaluate the epidemiology, clinicopathologic features, and outcome of invasive fusariosis in patients with hematologic cancer, we conducted a retrospective study of invasive fusarial infections in patients with hematologic malignancy treated at a referral cancer center over a 10-year period (1986 to 1995), as well as a literature review. Forty patients with disseminated and three patients with invasive lung infection were included in the analysis. All patients were immunocompromised. The infection occurred in three patients postengraftment following bone marrow transplantation. All patients were diagnosed antemortem. Thirteen patients responded to therapy, but the infection relapsed in two of them. Response was associated with granulocyte transfusions, amphotericin B lipid formulations (four patients each), and an investigational triazole (two patients). Resolution of infection was only seen in patients who ultimately recovered from myelosuppression. Portal of entry was the skin (33%), the sinopulmonary tree (30%), and unknown (37%). Fusarium causes serious morbidity and mortality, and may mimic aspergillosis. The infection seems to respond to newer therapeutic approaches, but only in patients with ultimate recovery from myelosuppression, and it may relapse if neutropenia recurs.

Fusarium, a Significant Emerging Pathogen in Patients With Hematologic Malignancy: Ten Years' Experience at a Cancer Center and Implications for Management

Despite increasing reports of life-threatening Fusarium infections, little is known about its pathogenesis and management. To evaluate the epidemiology, clinicopathologic features, and outcome of invasive fusariosis in patients with hematologic cancer, we conducted a retrospective study of invasive fusarial infections in patients with hematologic malignancy treated at a referral cancer center over a 10-year period (1986 to 1995), as well as a literature review. Forty patients with disseminated and three patients with invasive lung infection were included in the analysis. All patients were immunocompromised. The infection occurred in three patients postengraftment following bone marrow transplantation. All patients were diagnosed antemortem. Thirteen patients responded to therapy, but the infection relapsed in two of them. Response was associated with granulocyte transfusions, amphotericin B lipid formulations (four patients each), and an investigational triazole (two patients). Resolution of infection was only seen in patients who ultimately recovered from myelosuppression. Portal of entry was the skin (33%), the sinopulmonary tree (30%), and unknown (37%). Fusarium causes serious morbidity and mortality, and may mimic aspergillosis. The infection seems to respond to newer therapeutic approaches, but only in patients with ultimate recovery from myelosuppression, and it may relapse if neutropenia recurs.

Ecthyma gangrenosum-like lesions: a sign of disseminated Fusarium infection in the neutropenic patient

Fusarium is a saprophytic fungus of soil causing disease in plants and animals. In the immunocompetent patient, Fusarium is non-invasive, colonizing wounds, ulcers or nails. In the immunocompromised host, however, especially in those whose neutrophil and macrophage function is deficient, it can cause devastating systemic infections. Skin lesions are an early feature of the disseminated disease. Rapid diagnosis and treatment are mandatory in order to give the patient a better chance of survival, reported mortality rates being as high as 90%.

Fungal infections in neutropenic patients. A 8-year prospective study

In this paper we report a eight-year prospective study designed to further characterize incidence, epidemiology, specific syndromes, treatment and prognosis associated with fungal infections in neutropenic patients. During the study period 30 fungal infections were diagnosed in 30 patients among 313 episodes of fever and neutropenia (10%). There were 15 cases of candidiasis, 5 pulmonary aspergillosis, 3 sinusitis by Aspergillus fumigatus, 5 infections by Fusarium sp., one infection by Trichosporon sp., and one infection due to Rhodotorula rubra. Blood cultures were positive in 18 cases (60%). The predisposing factors for fungal infection in multivariate analysis were the presence of central venous catheter (p < 0.001), longer duration of profound (< 100/mm3) neutropenia (p < 0.001), the use of corticosteroids (p < 0.001), gram-positive bacteremia (p = 0.002) and younger age (p = 0.03). In multivariate analysis only recovery of the neutropenia (p < 0.001) was associated with good prognosis whereas the diagnosis of infection by Fusarium sp. (p = 0.006) was strongly associated with a poor outcome. The death rate was 43%. There was no statistically significant difference in the death rate between patients who did receive (52%) or did not receive (50%) antifungal treatment. Identifying patients at risk, specific syndromes and prognostic factors may help to reduce the high mortality associated with disseminated fungal infections in neutropenic patients.

Successful treatment of catheter-related fusarial infection in immunocompromised children

Fusarium infection is increasingly reported in immunocompromised patients. The role of central venous catheters as potential portals of entry for Fusarium is possibly underestimated. Four cases of catheter-related fusarial infection in children with acute leukemia or a solid tumor are described. These patients had an excellent response to removal of the central venous catheter and treatment with amphotericin B.

Mixed intranasal infection caused by Fusarium solani and a zygomycete in a leukaemic patient

We report a case of mixed intranasal infection caused by Fusarium solani and a zygomycete, with probable sinus and brain involvement. The patient had chronic myelogenous leukaemia and was treated with chemotherapy. Diagnosis of the infection was established by direct examination of the intranasal eschar and histopathological study of an excisional biopsy. Only F. solani was isolated from both specimens. Difficulties in diagnosis and treatment of these infections are discussed.

New and unusual infections in neutropenic patients

Infections in immunocompromised patients with cancer are common and the primary risk factor is neutropenia, usually induced by chemotherapeutic agents. The spectrum of bacterial infection is shifting from gram-negative to gram-positive. The array of fungal infections in cancer patients is expanding to include organisms previously unknown as invasive human pathogens. New species are being defined to explain extant pathologies, and free living algae are now emerging as pathogens in immunocompromised patients. Physicians must remain alert to these emerging pathogens and to the need to evaluate optimal treatments for the usual and unusual infections in neutropenic and other compromised patients with cancer and allied diseases.

Hyalohyphomycoses due to Fusarium spp.--two case reports and review of the literature

We report a case of a severe Fusarium solani keratitis in a 82-year-old patient with a history of surgical trauma. Antimycotic therapy and keratoplasty led to markedly improved vision. Identification of the fungus was complicated by the fact that the isolate did not produce the typical macroconidia. The second case was a fatal disseminated Fusarium verticillioides infection in a 69-year-old patient during neutropenia after chemotherapy of acute myelogenous leukemia. The patient developed pneumonia, fever, skin lesions, myalgia, and fungaemia. The clinical signs, diagnosis and therapy of localized and disseminated Fusarium infections are outlined and discussed in view of the literature.

Amphotericin B followed by itraconazole in the treatment of disseminated fungal infections in neutropenic patients

The role of the new triazoles in the treatment of disseminated fungal infections in neutropenic patients is at present under scrutiny. Six neutropenic patients with disseminated fungal infections were treated with amphotericin B during neutropenia and itraconazole after bone marrow recovery. There were three pulmonary aspergillomas, one Aspergillus fumigatus sinusitis, one Fusarium-mycosis and one disseminated candidosis. Four patients were cured of the infection. This approach seems to be safe and effective in the treatment of disseminated fungal infections in neutropenic patients, with the advantages of low side-effects and the possibility of early discharge from hospital.

Clinical patterns of Fusarium infections in immunocompromised patients

Fusarium is an ubiquitous fungus commonly found in soil and on plants. Human infection usually occurs as a result of inoculation of the organism through the body surface, thus causing skin infection, onychomycosis, keratitis, endophthalmitis and arthritis. Dissemination may occur in subjects with underlying immunodeficiency. Among immunocompromised hosts, Fusarium sp. is an emerging pathogen in neutropenic patients. To our knowledge, since 1973, when the first disseminated fusariosis in a child with acute leukemia was reported, about 80 new cases have been reported, mainly occurring in patients with haematologic malignancies. Specific portals of entry are not well understood, nevertheless the respiratory tract, colonised gastrointestinal tract, onychomycosis, disrupted skin barrier and central venous catheter have been reported as entry sites of deep seated Fusarium infections. Fever, positive blood cultures, severe myalgias, disseminated ecthyma gangrenosum-like skin lesions, ocular symptoms and multiple-organ-system involvement are distinctive features in most cases of disseminated fusariosis. The prognosis is very poor with death generally following despite antifungal therapy, unless an increase in the white blood cell count occurs. All available antifungal drugs show a low activity against the various species of Fusarium. Nevertheless, amphotericin B seems to have the highest in vitro activity and, even if it does not appear to be effective in persistently neutropenic patients, it should be currently considered to be the treatment of choice.