Survival after fungemia due to Fusarium moniliforme in a child with neuroblastoma

Fusarium infections in immunocompromised patients

Fusarium species cause a broad spectrum of infections in humans, including superficial, locally invasive, and disseminated infections. The clinical form of fusariosis depends largely on the immune status of the host and the portal of entry, with superficial and localized disease occurring mostly in immunocompetent patients and invasive and disseminated disease affecting immunocompromised patients. Risk factors for severe fusariosis include prolonged neutropenia and T-cell immunodeficiency, especially in hematopoietic stem cell transplant recipients with severe graft-versus-host disease. The most frequent presentation of disseminated fusariosis is a combination of characteristic cutaneous lesions and positive blood cultures, with or without lung or sinus involvement. The prognosis is poor and is determined largely by degree of immunosuppression and extent of infection, with virtually a 100% death rate among persistently neutropenic patients with disseminated disease. These infections may be clinically suspected on the basis of a constellation of clinical and laboratory findings, which should lead to prompt therapy. Treatment options include the lipid formulations of amphotericin B, voriconazole, and posaconazole. Prevention of fusarial infection among high-risk patients should be considered.

Emerging Fungi

The hyalohyphomycetes (especially Fusarium spp) have emerged as significant pathogens in severely immunocompromised patients. Human infections by Fusarium spp can be superficial or limited to single organs in otherwise healthy patients. Such infections are rare and tend to respond well to therapy. By contrast, disseminated fusarial hyalohyphomycosis affects the immunocompromised host and frequently is fatal. Successful outcome is determined by the degree of immunosuppression and the extent of the infection. These infections may be suspected clinically on the basis of a constellation of clinical and laboratory findings, which should lead to prompt therapy.

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.

Dimorphic fungus characteristic of fumonisin-producing strains of Fusarium moniliforme from Zhejiang

Fusarium moniliforme and its fumonisins have been shown to be carcinogenic in lab animals and have been linked to high incidences of human esophageal cancer. In this study we report the dimorphic fungus characteristic of fumonisin-producing strains of F. moniliforme from foodstuffs in Zhejiang, China. All of the twenty strains of F. moniliforme shown produce fumonisin B1 475.9-6322.2 micrograms/g in corn medium. These strains of F. moniliforme form yeast-like colonies in Sabouraud's agar plates contained 9% NaCl at 37 degrees C incubator and shows mostly budding reproduction. In blood agar plates these strains of F. moniliforme appear grass-green haemolytic reactions. This is the first report that yeast-like growth, dimorphic pathogenic fungus feature is found in F. moniliforme. These results suggest that it is also important to program epidemiological surveys of F. moniliforme as a primary pathogenic fungus, while proceeding to produce mycotoxins of F. moniliforme in food hygiene.

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.

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.

Fungaemia due to Fusarium spp. in cancer patients

Five cases of fungaemia due to Fusarium spp. in cancer patients are described. Two were breakthrough cases, despite ongoing therapy with amphotericin B. Three were caused by Fusarium solani, one by F. oxysporum and one by F. dimerum. Four patients died, three of them despite therapy with amphotericin B for between 5-37 days. We describe only the second reported case of F. dimerum fungaemia. Since 1972, 93 cases of systemic infection with Fusarium spp. have been described: 43 had positive blood cultures and the overall mortality was 72%.

Opportunistic fusarial infections in humans

Fusarium species are common hyaline soil saprophytes and plant pathogens which have frequently been reported as etiologic agents of opportunistic infections in humans. These infections have usually been limited to superficial mycoses, but recently the number of infections of deep tissues and disseminated infections has greatly increased, especially in patients with an underlying immunosuppressive condition. The characteristic signs of these infections are disseminated skin nodules, fungemia and multiorgan involvement. Frequently, myalgia is also present. Skin involvement occurred in over 80% of cases of disseminated infections. These lesions are significant because they are readily accessible for biopsy and culture, thus permitting an early diagnosis. The therapy and outcome are dependent on the degree of invasion of the organisms and the status of the host. Identification of the pathogen to genus level is not difficult, but identification to species level requires a greater degree of expertise. Up to now, 15 species of Fusarium have been reported to cause infections in humans and animals. Few patients with disseminated fusarial infections have survived, even after receiving an adequate dosage of amphotericin B, the only antifungal agent that has some effect against these fungi. In vitro susceptibility to amphotericin B is a poor predictor of the clinical outcome of invasive fungal infections. Recovery of the phagocytic mechanisms in the form of rising neutrophil counts appears to be mandatory for clinical resolution. The resolution of neutropenia may be aided by the use of exogenous growth factors. Outside the USA, the majority of cases of disseminated fusarial infection have been reported from Mediterranean or tropical countries.

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.

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.