Combined voriconazole plus caspofungin therapy for the treatment of probable Geotrichum pneumonia in a leukemia patient

Geotrichosis: fungemia in a patient with acute lymphoblastic leukemia

Fungemia caused by Geotrichum spp. is rare and highly lethal. The Instituto Nacional de Cancerología in Bogotá reported just two cases: one in the period 2001-2007 and the other in 2012-2018. This type of infection is more common in any kind of immunocompromised patients, so it can occur in those with hematological malignancies. Here we present the case of a 27-year-old man, diagnosed with acute lymphoblastic leukemia in relapse and admitted with polyarthralgia for five days, febrile neutropenia, nonabscessed cellulitis, and bacteremia due to methicillin-sensitive Staphylococcus aureus. The patient received therapy with oxacillin and cefepime, but the febrile neutropenia persisted. A new set of blood cultures was taken, and antifungal treatment was started because of the suspicion of invasive fungal infection. Arthroconidia were identified in blood cultures and Geotrichum spp. was confirmed using matrix-assisted laser desorption-ionization mass spectrometry. The antifungal treatment was adjusted with amphotericin B deoxycholate for 14 days and voriconazole for four weeks, and after a prolonged stay, the patient was discharged. Although the incidence of fungemia caused by Geotrichum spp. is low, it must be considered in patients with hematological malignancies and persistent febrile neutropenia despite the broadspectrum antimicrobial treatment. The confirmation of fungemia causing agents, with proteomic tools such as the mentioned mass spectrometry, allows treatment adjustment and decreases complications, hospital stay, and mortality.

Disseminated Saprochaete capitata fungal infection in a patient with acute myeloid leukemia

The case highlights the importance of actively obtaining informative samples at an early stage and of prompt initiation of combination therapy with antifungal drugs.

Invasive Saprochaete Infections: An Emerging Threat to Immunocompromised Patients

Saprochaete clavata and Saprochaete capitata are emerging fungal pathogens that are responsible for life threatening infections in immunocompromised patients, particularly in the setting of profound neutropenia. They have been associated with multiple hospital outbreaks mainly in Europe. In this article, we present a comprehensive review of the epidemiology, clinical presentation, diagnosis, antifungal susceptibility and treatment of these organisms. The diagnosis of invasive Saprochaete disease is challenging and relies primarily on the isolation of the fungi from blood or tissue samples. Both species are frequently misidentified as they are identical macroscopically and microscopically. Internal transcribed spacer sequencing and matrix-assisted laser desorption ionization-time of flight mass spectrometry are useful tools for the differentiation of these fungi to a species level. Saprochaete spp. are intrinsically resistant to echinocandins and highly resistant to fluconazole. Current literature suggests the use of an amphotericin B formulation with or without flucytosine for the initial treatment of these infections. Treatment with extended spectrum azoles might be promising based on in vitro minimum inhibitory concentration values and results from case reports and case series. Source control and recovery of the immune system are crucial for successful therapy.

An Overview of the Management of the Most Important Invasive Fungal Infections in Patients with Blood Malignancies

In patients with hematologic malignancies due to immune system disorders, especially persistent febrile neutropenia, invasive fungal infections (IFI) occur with high mortality. Aspergillosis, candidiasis, fusariosis, mucormycosis, cryptococcosis and trichosporonosis are the most important infections reported in patients with hematologic malignancies that undergo hematopoietic stem cell transplantation. These infections are caused by opportunistic fungal pathogens that do not cause severe issues in healthy individuals, but in patients with hematologic malignancies lead to disseminated infection with different clinical manifestations. Prophylaxis and creating a safe environment with proper filters and air pressure for patients to avoid contact with the pathogens in the surrounding environment can prevent IFI. Furthermore, due to the absence of specific symptoms in IFI, rapid and accurate diagnosis reduces the mortality rate of these infections and using molecular techniques along with standard mycological methods will improve the diagnosis of disseminated fungal infection in patients with hematologic disorders. Amphotericin B products, extended-spectrum azoles, and echinocandins are the essential drugs to control invasive fungal infections in patients with hematologic malignancies, and according to various conditions of patients, different results of treatment with these drugs have been reported in different studies. On the other hand, drug resistance in recent years has led to therapeutic failures and deaths in patients with blood malignancies, which indicates the need for antifungal susceptibility tests to use appropriate therapies. Life-threatening fungal infections have become more prevalent in patients with hematologic malignancies in recent years due to the emergence of new risk factors, new species, and increased drug resistance. Therefore, in this review, we discuss the different dimensions of the most critical invasive fungal infections in patients with hematologic malignancies and present a list of these infections with different clinical manifestations, treatment, and outcomes.

Rare severe mycotic infections in children receiving empirical caspofungin treatment for febrile neutropenia

Empirical antifungal therapy is most often given to patients with leukemia. However breakthrough fungal infections under antifungal therapy are not uncommon. Four children, with hematologic malignant disease developed mycotic breakthrough infections while on empirical caspofungin treatment for a median of 14 (range 11–19) days. Trichosporon asahii was detected in the blood culture of two patients and Geotrichum capitatum in the other two (one patient also had positive cerebrospinal fluid culture). Because the patients’ clinical situation worsened, voriconazole was empirically added for two patients three and five days before the agent was detected. The first sterile blood culture was obtained 3–7 days of voriconazole treatment. All patients reached clear cultures but one patient died. One patient with central nervous system infection with G. capitatum had severe neurological sequelae. Very severe fungal infections can occur during empirical caspofungin therapy. Therefore, patients should be followed closely.

Epidemiology and outcome of systemic infections due to saprochaete capitata: case report and review of the literature

A case of systemic infection due to Saprochaete capitata in a patient with chronic lymphocytic leukemia is described. A review of the literature was conducted to identify all reported cases of this infection described between 1977 and August 2013. One hundred and four cases (included the present one) were identified. The median age of the patients was 56 years and 56% were males. Comorbidities included acute myeloid leukemia (52%), acute lymphoid leukemia (22%), other hematological malignancies (13%) and non-hematological diseases (9%). At the time of the infection, 82% of the patients were neutropenic. In 75% of the cases, the yeast was isolated from blood culture, in 25% from other sterile sites. Empirical treatment was done in 36% of the cases. Fifty-eight percent of the individual cases were treated with a combination or a sequential antifungal therapy. Amphotericin B was the antifungal drug most commonly used, followed by voriconazole and itraconazole. The overall crude mortality was 60%. Saprochaete capitata causes life-threatening infections in neutropenic patients. This comprehensive literature review may help the clinician to optimize the management of this rare infection.

Geotrichum capitatum septicemia in patients with acute myeloid leukemia. Report of three cases

Geotrichum capitatum infection is uncommon, and has been exclusively reported in immunocompromised patients. The prognosis is poor with a mortality rate ranging from 50 to 90%. We report 3 cases of Geotrichum capitatum fungemia in neutropenic patients receiving chemotherapy for acute myeloblastic leukemia. The infection was successfully cured with voriconazole in 1 case and was fatal in the 2 remaining cases despite treatment with amphotericin B.

Breakthrough Saprochaete capitata infections in patients receiving echinocandins: case report and review of the literature

We report a rare case of a fatal Saprochaete capitata breakthrough infection in a patient with acute myeloid leukemia receiving empirical caspofungin therapy. S. capitata is an uncommon, yet emerging cause of invasive infections, especially in patients with haematological malignancies. Blood cultures from our patient yielded S. capitata which was found to be resistant, in vitro, to caspofungin. We consecutively reviewed all published cases of breakthrough infections caused by S. capitata in patients receiving echinocandins. S. capitata should be considered in those patients who remain febrile or who develop invasive mould infections while under echinocandin therapy.

Successful treatment of systemic Geotrichum capitatum infection by liposomal amphotericin-B, itraconazole, and voriconazole in a Japanese man

Severe systemic Geotrichum capitatum (G. capitatum) infection is rare, especially in Japan. G. capitatum infection has been reported mainly in immunocompromised patients and the prognosis is poor with a mortality rate of approximately 50-75%. Here, we report a Japanese case of systemic G. capitatum infection in a severe neutropenic patient who was receiving chemotherapy for acute myelogeneous leukemia with multilineage dysplasia. G. capitatum was isolated from blood cultures, and also formed multiple nodular lesions in lung fields. The infection was successfully cured with a combination of amphotericin B, itraconazole, and voriconazole.

Pharmacotherapy of yeast infections

The rise of immunocompromised individuals in our society has provoked a significant emergence in the number of patients affected by opportunistic pathogenic yeast. The microorganisms with a major clinical incidence are species from the genera Candida (especially Candida albicans) and Cryptococcus (particularly Cryptococcus neoformans), although there has been a significant increase in other pathogenic yeasts, such as Trichosporon spp. and Rhodotorula spp. In addition, there are an increasing number of patients infected by yeasts that were not previously considered as pathogenic, such as Saccharomyces cerevisiae. The management of these infections is complicated and is highly dependent on the susceptibility profile not only of the species but also of the strain. The available antifungal compounds belong mainly to the polyene, azole and candin families, which show a distinct spectrum of activity. This review summarizes the current knowledge about the use of the main antifungals for treating infections caused by the yeast species with the most significant clinical relevance, including the susceptibility profiles exhibited by these species in vitro.