Hepatosplenic candidiasis in patients with acute leukaemia

Successful Treatment of Chronic Disseminated Candidiasis Complicated by Immune Reconstitution Inflammatory Syndrome in a Child With Acute Lymphocytic Leukemia

Chronic disseminated candidiasis (CDC) is a severe form of disseminated fungal infection that commonly affects the liver, spleen, and kidneys. In rare cases, CDC can be further complicated by an excessive immune response known as immune reconstitution inflammatory syndrome (IRIS). This syndrome occurs during the phase of immune recovery and is characterized by a systemic inflammatory response and excessive release of cytokines. We present a case of a two-year-old female with a medical history of acute lymphocytic leukemia on chemotherapy. She was admitted with high fever refractory to conservative management that included broad-spectrum antimicrobials. Additionally, multiple skin lesions and a left-sided limp were noted. Whole-body imaging revealed multiple abscesses in the spleen, kidneys, scalp, and left lower limb. The culture of an aspirate material from skin lesions grew Candida tropicalis. Despite receiving appropriate antifungals, the patient showed no signs of improvement, leading to the diagnosis of CDC-induced IRIS. The patient was started on systemic corticosteroids, which resulted in rapid improvement in the patient's clinical status, resolution of fever, and significant reduction in inflammatory markers.

Subcutaneous Microabscesses and Myositis as Part of Immune Reconstitution Inflammatory Syndrome due to Chronic Disseminated Candidiasis in a Child With Acute Lymphoblastic Leukemia

BACKGROUND

Immune reconstitution inflammatory syndrome (IRIS) occurs when there is immune recovery after a prolonged period of leucopenia as a response to an underlying latent or chronic infection due to a proinflammatory cascade. It can occur in a child on chemotherapy for acute lymphoblastic leukemia (ALL) with underlying chronic disseminated candidiasis (CDC).

OBSERVATION

We present a 7-year-old girl with pre-B ALL on chemotherapy who had prolonged febrile neutropenia and CDC with microabscesses in the liver, spleen, and kidney and a prolonged intensive care unit stay. Upon neutrophil recovery, she continued to have high-grade fever (blood and urine cultures negative). She also presented severe myositis of bilateral thigh muscles and developed unusual granulomas in the subcutaneous region of the lower back and right thigh. Although IRIS was suspected, she could not be initiated on steroids due to right upper lobe collapse consolidation due to multidrug-resistant Acinetobacter baumanni, which was treated with sensitive antibiotics. Treatment with steroids resolved her fever and normalized inflammatory markers. She is currently well on maintenance chemotherapy.

CONCLUSIONS

IRIS can complicate the treatment of ALL in children. Diagnosing it while having a concurrent bacterial infection is challenging. Rarely CDC can present with subcutaneous granulomas. Treatment with steroids at the right time is very crucial.

Hepatosplenic candidiasis in patients with hematological malignancies: a 13-year retrospective cohort study

Background

Hepatosplenic candidiasis (HSC) used to be reported in patients with acute myeloid leukemia (AML) without antifungal prophylaxis. The aim was to describe the clinical features and outcomes of HSC over the last 13 years in a single French hematology center.

Methods

All patients diagnosed with HSC between 2008 and 2020 were included in a single-center retrospective cohort study. Data were collected from patient charts, and HSC was classified according to the 2020 European Organisation for Research and Treatment of Cancer/Mycoses Study Group definitions.

Results

Sixty patients were included, with 18.3% proven, 3.3% probable, and 78.3% possible HSC according to the 2020 European Organization for Research and Treatment of Cancer Mycoses Study Group classification. Among them, 19 patients were treated for acute myeloid leukemia (AML), 21 for lymphomas, and 14 for acute lymphoblastic leukemia. HSC occurred in 13 patients after autologous stem cell transplantation for lymphoma. At HSC diagnosis, 13 patients were receiving antifungal prophylaxis. Candida colonization was present in 84.2%, with prior candidemia in 36.7% of cases. β-D-glucans was positive in 55.8%, and 45.8% of tissue biopsies were contributive. First-line antifungal therapy was azoles in 61.7%, and steroids were associated in 45% of cases. At 3 months of follow-up, partial response to antifungal therapy was 94.2%. At last follow-up (mean, 22.6 months), 41 patients (68.3%) presented a complete hematological remission and 22 patients were deceased, none because of HSC.

Conclusions

The epidemiology of HSC has changed in the last decade, with fewer cases occurring in the AML setting. A better identification of patients at risk could lead to specific prophylaxis and improved diagnosis.

Candidemia and Invasive Candidiasis

Invasive candidiasis (IC) is a collective term that refers to a group of infectious syndromes caused by a variety of species of Candida, 6 of which cause most cases globally. Candidemia is probably the most commonly recognized syndrome associated with IC; however, Candida can cause invasive infection of any organ, especially visceral organs, vasculature, bones and joints, the eyes and central nervous system. Targeted prevention and empirical therapy are important interventions for patients at high risk for IC, and the current approach should be based on a combination of clinical risk factors and non-culture-based diagnostics, when available.

Case Report: Proven Diagnosis of Culture-Negative Chronic Disseminated Candidiasis in a Patient Suffering From Hematological Malignancy: Combined Application of mNGS and CFW Staining

Chronic disseminated candidiasis (CDC) is a severe complication with high morbidity and mortality in patients with hematological malignancies who have undergone chemotherapy. Blood or sterile liver biopsy cultures are negative due to recurrent empirical antifungal therapy. With the escalating resistance to azole-based antifungal drugs in infection by Candida species, pathogen identification is becoming increasingly important for determining definitive diagnosis and treatment strategy. In this case report, we present, for the first time, diagnostic confirmation of a culture-negative CDC case with Candida tropicalis infection using a combination of metagenomics next-generation sequencing and calcofluor white staining.

Clinical feature, image findings and outcome of hepatosplenic candidiasis in patients with acute myeloid leukemia

Background

Patients with acute myeloid leukemia (AML) are at risk of hepatosplenic candidiasis (HSC). HSC is often associated with prolonged fever and difficulty in definitive clinical diagnosis. We aimed to explore the incidence, clinical features, image findings and outcomes of HSC among patients with AML in a tertiary hospital, Taiwan.

Methods

We did a chart review of patient data in our institute from 2009 to 2012. The diagnosis of HSC was based on risk factors, febrile symptoms and image findings.

Results

Two hundred and ninety-two patients with AML were analyzed. In total, 1051 chemotherapy sessions were administered. Eleven patients (4 males and 7 females) experienced HSC (incidence 3.8%, 95% conference interval 2.11–6.72%). Among those with HSC, the median age was 62. Eight patients developed HSC following induction or re-induction chemotherapies. Three developed HSC following consolidation chemotherapies. The median duration of severe neutropenia was 25 days (range 10–142). In all patients with HSC, multiple hypodense lesions were found in the involved organs by computed tomography scans. Lesions consistent with HSC could be identified by ultrasound in 5 out of 6 patients. Other than liver and spleen, lung was frequently (7 cases) and kidney occasionally (3 cases) involved. Four patients died within 90 days. Prolonged neutropenia was associated with mortality.

Conclusion

HSC occurred more often during induction or re-induction periods. Lungs are commonly involved and pleural effusion was frequently seen in CT scans. Pleural effusion may suggest more serious infections but its clinical relevance should be investigated in large-scale studies. Prolonged neutropenia is the only prognostic factor. Prophylaxis should be considered. In the absence of prophylaxis, we advise early image studies and prompt antifungal treatment in patients at risk for HSC.

Hepatosplenic Fungal Infections in Children With Leukemia-Risk Factors and Outcome: A Multicentric Study

BACKGROUND

Invasive fungal infections, including hepatosplenic fungal infections (HSFI), cause significant morbidity and mortality in children with leukemia. There are not enough data to support for the best approach to diagnosis of HSFI in children, nor for the best treatment.

PROCEDURE

In this multicentric study, we assessed the demographic data, clinical and radiologic features, treatment, and outcome of 40 children with leukemia and HSFI from 12 centers.

RESULTS

All cases were radiologically diagnosed with abdominal ultrasound, which was performed at a median of 7 days, of the febrile neutropenic episode. Mucor was identified by histopathology in 1, and Candida was identified in blood cultures in 8 patients. Twenty-two had fungal infection in additional sites, mostly lungs. Nine patients died. Four received a single agent, and 36 a combination of antifungals.

CONCLUSIONS

Early diagnosis of HSFI is challenging because signs and symptoms are usually nonspecific. In neutropenic children, persistent fever, back pain extending to the shoulder, widespread muscle pain, and increased serum galactomannan levels should alert clinicians. Abdominal imaging, particularly an abdominal ultrasound, which is easy to perform and available even in most resource-limited countries, should be recommended in children with prolonged neutropenic fever, even in the absence of localizing signs and symptoms.

Changes in the epidemiological landscape of invasive candidiasis

The epidemiology of invasive candidiasis has evolved in recent years, warranting a review of the changes and the implications for current and future diagnosis and treatment. The overall burden of invasive candidiasis remains high, particularly in the expanding populations of patients at risk of opportunistic infection, such as the elderly or immunosuppressed. Progressive shifts from Candida albicans to non-albicans Candida spp. have been observed globally. The recent emergence of novel, multiresistant species, such as Candida auris, amplifies the call for vigilance in detection and advances in treatment. Among the current treatment options, fluconazole is still widely used throughout the world. Increased resistance to fluconazole, both acquired and naturally emerging, has been observed. Resistance to echinocandins is presently low but this may change with increased use. Improvement of diagnostic techniques and strategies, development of international surveillance networks and implementation of antifungal stewardship programmes represent major challenges for a better epidemiological control of invasive candidiasis.

Clinical characteristics and outcomes of patients with chronic disseminated candidiasis who need adjuvant corticosteroid therapy

We performed a retrospective study involving 21 patients with chronic disseminate candidiasis (CDC) and 38 patients with candidemia. Neutropenia of >2 weeks' duration was more common in those with CDC (71%) than in those with candidemia (26%, P < .001), and the azole-resistant rate in patients with CDC (5%) was lower than that in those with candidemia (29%, P = .03). Of the 21 patients with CDC, five (24%) needed adjuvant corticosteroid therapy due to persistent debilitating fever (median, 19 days). Rapid defervescence (median, 5 days) occurred after adjuvant corticosteroid therapy. However, there were no significant differences in 90-day mortality between CDC patients with and without corticosteroid therapy. Further prospective data are needed to define the role of steroids in this setting.

Response of Symptomatic Persistent Chronic Disseminated Candidiasis to Corticosteroid Therapy in Immunosuppressed Pediatric Patients: Case Study and Review of the Literature

BACKGROUND

Chronic disseminated candidiasis (CDC) is a severe invasive fungal infection principally observed during neutrophil recovery in patients with acute leukemia treated with intensive chemotherapy. Its pathophysiology remains unclear. We describe the management of 6 children with symptomatic CDC who did not respond to antifungal therapy.

METHODS

The databases of the hematology-oncology departments of 2 tertiary pediatric medical centers were searched for all patients diagnosed with CDC from 2003 to 2015, who responded to corticosteroids after failing antifungal therapy. Clinical, laboratory and radiologic data were collected.

RESULTS

Six patients (3 women, 3 men; 9-18 years of age) met the study criteria. Underlying diseases were acute lymphoblastic leukemia (n = 3) and large B-cell lymphoma, acute myeloid leukemia and severe aplastic anemia (n = 1 each). Presenting symptoms/signs of CDC were fever in all cases, with abdominal or chest pain, and/or mucositis. Candida infection was identified in blood cultures in 4 patients and in bronchoalveolar lavage fluid in one. In the absence of response to antifungal agents (4-50 days from CDC diagnosis), prednisone 2 mg/kg/day or equivalent was administered. CDC-attributable clinical symptoms resolved in 4 patients within 6-19 days; one patient required an additional nonsteroidal anti-inflammatory agent. Abnormalities on imaging decreased or disappeared within 5 months to 2 years in 4 patients.

CONCLUSIONS

In children with persistent symptomatic CDC, despite adequate antifungal therapy, administration of corticosteroids may yield rapid resolution of symptoms and decreased inflammatory markers. In patients who do not respond to steroids, the addition of a nonsteroidal anti-inflammatory drug should be considered.

Liver fungal infections: an overview of the etiology and epidemiology in patients affected or not affected by oncohematologic malignancies

Fungal infections of the liver, most commonly caused by Candida spp., often occur in patients with hematologic malignancies treated with chemotherapy. Colonization of the gastrointestinal tract is thought to be the main origin of dissemination of Candida; mucositis and neutropenia facilitate the spread of Candida from the gastrointestinal tract to the liver. Hepatic involvement due to other fungi is a less common infectious complication in this setting. Fungal infections represent a less common cause of hepatic abscesses in non-oncohematologic population and the trend appears to be decreasing in recent years. Understanding of the etiology and epidemiology of fungal infections of the liver is indicated for an appropriate antimicrobial therapy and an overall optimal management of fungal liver infections.

Hepatosplenic Candidiasis Without Prior Documented Candidemia: An Underrecognized Diagnosis?

Hepatosplenic candidiasis (HSC) often occurs without prior documented candidemia. Underrecognized HSC can be mistaken for metastases and can have serious consequences for patients, especially when additional, inappropriate treatment, such as surgery and chemo‐ or immunotherapy, is initiated. To emphasize the importance of diagnosing HSC without prior documented candidemia, three illustrative cases and a review of the literature on HSC and candidemia are presented.

Introduction.

Patients with a history of chemotherapy or stem cell transplantation (SCT) and prolonged neutropenia are at risk for hepatic and/or splenic seeding of Candida. In our experience, hepatosplenic candidiasis (HSC) without documented candidemia often remains unrecognized.

Case presentations.

We describe three cases of HSC without documented candidemia and the challenges in establishing the diagnosis and adequately treating this condition. The first patient had a history of SCT for treatment of breast cancer and was scheduled for hemihepatectomy for suspected liver metastasis. A second opinion at our institute resulted in the diagnosis of hepatic candidiasis without prior documented candidemia, for which she was treated successfully with fluconazole. The second case demonstrates the limitations of (blood and tissue) cultures and the value of molecular methods to confirm the diagnosis. Case 3 illustrates treatment challenges, with ongoing dissemination and insufficient source control despite months of antifungal therapy, eventually resulting in a splenectomy.

Literature review.

A structured literature search was performed for articles describing any patient with HSC and documented blood culture results. Thirty articles were available for extraction of data on candidemia and HSC. Seventy percent (131/187) of patients with HSC did not have documented candidemia. The majority of HSC events were described in hematologic patients, although some cases were described in patients with solid tumors treated with SCT (n = 1) or chemotherapy and a history of leukopenia (n = 2). Current guidelines and practices for diagnosis and treatment are described.

Conclusion.

Clinicians should be aware that HSC most often occurs without documented candidemia. In case of persistent or unexplained fever or lesions in the liver and/or spleen, a history of neutropenia should place disseminated candidiasis in the differential diagnosis. HSC is not limited to hematological patients and may occur in patients with solid tumors treated with bone marrow‐suppressing chemotherapy or SCT. In the latter group, HSC as alternative diagnosis for hepatic metastasis should be considered when lesions are not typical for metastasis. This might prevent unnecessary surgery or inappropriate treatment.

Implications for Practice.

Timely diagnosis of hepatosplenic candidiasis (HSC) is challenging, but can prevent further complications and dissemination, and may even prevent unnecessary invasive procedures. Clinicians should realize that HSC often occurs without documented candidemia and that sensitivity of blood cultures for candidemia is limited. HSC is not strictly limited to hematologic patients and might also occur in patients with solid tumors treated with intensive chemotherapy or stem cell transplantation. Increased awareness for HSC in patients with any history of neutropenia is of importance to increase detection and prevent serious sequelae.

Chronic Disseminated Candidiasis Complicated by Immune Reconstitution Inflammatory Syndrome in Child with Acute Lymphoblastic Leukemia

Hepatosplenic candidiasis also known as chronic disseminated candidiasis is a rare manifestation of invasive fungal infection typically observed in patients with acute leukemia in prolonged, deep neutropenia. Immune reconstitution inflammatory syndrome (IRIS) is an inflammatory disorder triggered by rapid resolution of neutropenia. Diagnosis and treatment of IRIS are still challenging due to a variety of clinical symptoms, lack of certain diagnostic criteria, and no standards of treatment. The diagnosis of IRIS is even more difficult in patients with hematological malignancies complicated by “probable” invasive fungal infection, when fungal pathogen is still uncertain. We report a case of probable hepatic candidiasis in 4-year-old boy with acute lymphoblastic leukemia. Despite proper antifungal therapy, there was no clinical and radiological improvement, so diagnosis of Candida-related IRIS was made and corticosteroid therapy was added to antifungal treatment achieving prompt resolution of infection symptoms.

Invasive Candidiasis

Invasive candidiasis is a collective term that refers to a group of infectious syndromes caused by a variety of species of Candida, 5 of which cause most cases. Candidemia is the most commonly recognized syndrome associated with invasive candidiasis. Certain conditions may influence the likelihood for one species versus another in a specific clinical scenario, and this can have important implications for selection of antifungal therapy and the duration of treatment. Molecular diagnostic technology plays an ever-increasing role as an adjunct to traditional culture-based diagnostics, offering significant potential toward improvement in patient care.

[Recommendations for the management of candidemia in children in Latin America. Grupo Proyecto Épico]

Candidemia is one of the most frequent opportunistic mycoses worldwide. Limited epidemiological studies in Latin America indicate that incidence rates are higher in this region than in the Northern Hemisphere. Diagnosis is often made late in the infection, affecting the initiation of antifungal therapy. A more scientific approach, based on specific parameters, for diagnosis and management of candidemia in Latin America is warranted. 'Recommendations for the diagnosis and management of candidemia' are a series of manuscripts that have been developed by members of the Latin America Invasive Mycosis Network. They aim to provide a set of best-evidence recommendations for the diagnosis and management of candidemia. This publication, 'Recommendations for the management of candidemia in children in Latin America', was written to provide guidance to healthcare professionals on the management of children who have, or who are at risk of, candidemia. Computerized searches of existing literature were performed by PubMed. The data were extensively reviewed and analyzed by members of the group. The group also met on two occasions to pose questions, discuss conflicting views, and deliberate on a series of management recommendations. 'Recommendations for the management of candidemia in children in Latin America' includes prophylaxis, empirical therapy, therapy for proven candidemia, patient work-up following diagnosis of candidemia, duration of candidemia treatment, and central venous catheter management in children with candidemia. This manuscript is the third of this series that deals with diagnosis and treatment of invasive candidiasis. Other publications in this series include: 'Recommendations for the diagnosis of candidemia in Latin America', 'Recommendations for the management of candidemia in adults in Latin America', and 'Recommendations for the management of candidemia in neonates in Latin America'.

Recommendations for the management of candidemia in children in Latin America. Latin America Invasive Mycosis Network

Candidemia is one of the most frequent opportunistic mycoses worldwide. Limited epidemiological studies in Latin America indicate that incidence rates are higher in this region than in the Northern Hemisphere. Diagnosis is often made late in the infection, affecting the initiation of antifungal therapy. A more scientific approach, based on specific parameters, for diagnosis and management of candidemia in Latin America is warranted. 'Recommendations for the diagnosis and management of candidemia' are a series of manuscripts that have been developed by members of the Latin America Invasive Mycosis Network. They aim to provide a set of best-evidence recommendations for the diagnosis and management of candidemia. This publication, 'Recommendations for the management of candidemia in children in Latin America', was written to provide guidance to healthcare professionals on the management of children who have, or who are at risk of, candidemia. Computerized searches of existing literature were performed by PubMed. The data were extensively reviewed and analyzed by members of the group. The group also met on two occasions to pose questions, discuss conflicting views, and deliberate on a series of management recommendations. 'Recommendations for the management of candidemia in children in Latin America' includes prophylaxis, empirical therapy, therapy for proven candidemia, patient work-up following diagnosis of candidemia, duration of candidemia treatment, and central venous catheter management in children with candidemia. This manuscript is the third of this series that deals with diagnosis and treatment of invasive candidiasis. Other publications in this series include: 'Recommendations for the diagnosis of candidemia in Latin America', 'Recommendations for the management of candidemia in adults in Latin America', and 'Recommendations for the management of candidemia in neonates in Latin America'.

Clinical characteristics and the usefulness of the QuantiFERON-TB Gold In-Tube test in hematologic patients with hepatic or splenic lesions

BACKGROUND/AIMS

Hepatic or splenic lesions in hematologic patients are not defined well because they are not easy to evaluate due to limitations of invasive procedures. Management typically depends on the clinical diagnosis with few microbiological data.

METHODS

We reviewed the medical records of consecutive hematologic patients with hepatic or splenic lesions in the infectious diseases unit from April 2009 to December 2010 at the Catholic Hematopoietic Stem Cell Transplantation Center in Korea.

RESULTS

Twenty-six patients were identified. Their mean age was 46.0 ± 14.7 years, and 16 (61.5%) were male. Underlying diseases were acute myelogenous leukemia (n = 15, 57.7%) and myelodysplastic syndrome (n = 6, 23.1%). Among the nine nontuberculous infectious lesions, two bacterial, six fungal, and one combined infection were identified. The numbers of confirmed, probable, and possible tuberculosis (TB) cases were one, three, and four, respectively. Two patients had concurrent pulmonary TB. QuantiFERON-TB Gold In-Tube (QFT-GIT, Cellestis Ltd.) was positive in seven cases, among which six were diagnosed with TB. The sensitivity and specificity of QFT-GIT were 75% and 81.3%. Nine (34.6%) were defined as noninfectious causes.

CONCLUSIONS

Causes of hepatic or splenic lesion in hematologic patients were diverse including TB, non-TB organisms, and noninfectious origins. TB should be considered for patients not responding to antibacterial or antifungal drugs, even in the absence of direct microbiological evidence. QFT-GIT may be useful for a differential diagnosis of hepatosplenic lesions in hematologic patients.

Infections in patients with hematologic neoplasms and hematopoietic stem cell transplantation: neutropenia, humoral, and splenic defects

Infections are common in patients with hematologic neoplasms and following allogeneic hematopoietic transplantation. Neutropenia and defects in adaptive B-cell-mediated immunity and/or lack of splenic function predispose patients to a host of diverse and often serious infections. It is important to recognize that patients who undergo treatment for hematologic neoplasms may have mixed immune defects, and their vulnerability to infection may continue to change, in part as a reflection of the dynamic developments in the practice of oncology. The main obstacle in providing targeted, evidence-based antimicrobial treatment is the unpredictable results of even the new generation of diagnostic assays. A definite diagnosis for most end-organ opportunistic diseases requires tissue samples that are seldom available. Because immune defects may coexist, empirical therapy is directed toward a wide spectrum of pathogens. Real-time information about innate and adaptive immune functions and the role of acute and chronic phase molecules may improve target-specific therapy.

Clinical characteristics of hepatosplenic fungal infection in pediatric patients

BACKGROUND

Hepatosplenic fungal infection (HSF) is a distinct form of invasive fungal infection with main involvement of the liver, spleen, and occasionally the kidney. In this study, we investigated the clinical characteristics and outcomes of patients with HSF in childhood.

METHODS

We retrospectively reviewed pediatric patients with the diagnosis of HSF in a tertiary medical center in Taiwan between July 1999 and June 2009. The definition of HSF included imaging studies demonstrating multiple focal lesions in the liver and/or spleen with or without a microbiologic evidence for fungal infection. The clinical characteristics and outcomes were analyzed.

RESULTS

We identified 15 pediatric patients with HSF. Eleven patients had diagnosis of hemato-oncologic malignancy, and two patients had severe aplastic anemia. All patients had fever, and most patients had abdominal pain, nausea, vomiting, and hepatosplenomegaly. The detection rate of computed tomography scan (15/15, 100%) was superior to abdominal sonography (10/15, 67%, p = 0.01). Ten (91%) of the 11 patients with microbiologic evidence were infected by Candida species. Neither recurrence nor breakthrough fungal infection was noted when the patients underwent further chemotherapy and stem cell transplantation. Six patients (40%) died before the end of the study, but no mortality was directly related to HSF.

CONCLUSION

Candida species was the major pathogen for HSF, and computed tomography scan was a good diagnostic tool to detect the multiple focal lesions. Under adequate antifungal treatment, HSF could be cured without recurrence in spite of further chemotherapy and stem cell transplantation.

Diffuse liver disease: strategies for hepatic CT and MR imaging

The liver plays several complex but essential roles in the metabolism of amino acids, carbohydrates, and lipids, as well as synthesis of proteins. The basic pathophysiology of diffuse parenchymal hepatic diseases usually represents a failure in one of these metabolic pathways. Specific parenchymal diseases can be categorized as storage, vascular, and inflammatory diseases. Cross-sectional hepatic imaging techniques, specifically multidetector computed tomography (CT) and magnetic resonance (MR) imaging, have roles in evaluation of diffuse liver disease. The prominent role of multidetector CT is primarily defined by its excellent morphologic visualization capabilities, in particular of diffuse or focal intrahepatic lesions as well as of anatomic relationships between the liver and adjacent organs. The variety of available multidetector CT scanners covers a huge spectrum of detector configurations ranging from equally sized and equally spaced detector arrays to asymmetric detector configurations, resulting in imaging protocols with unique parameters for almost each multidetector CT system. In addition to 64-detector row imaging, hepatic multidetector CT can be performed with emerging techniques such as dual-energy CT. Hepatic MR imaging has been proved to be a comprehensive modality for assessing the morphology and functional characteristics of the liver. Concurrent technical improvements as well as implementation of advanced imaging sequence designs permit high-quality examination of the liver with T1-, T2-, and diffusion-weighted pulse sequences. Three basic demands remain if MR imaging is chosen for hepatic imaging: to improve parenchymal contrast, to suppress respiratory motion, and to ensure complete anatomic coverage. Supplemental material available at http://radiographics.rsna.org/content/29/6/1591/suppl/DC1.

[Hepatosplenic candidiasis in acute leukaemia patients]

INTRODUCTION

Hepatosplenic candidiasis is a disseminated invasive fungal infection that may affects patients with acute leukaemia. The main clinical manifestation is a persistent fever in patients recovered from prolonged neutropenia after recent chemotherapy.

CASE OUTLINE

The authors present three patients, two women and one men, aged 23, 26 and 33 years, with acute leukaemia; one with acute myeloblastic and two with acute lymphoblastic leukaemia who developed hepatosplenic candidiasis. The diagnosis was based on prolonged fever, elevated serum bilirubin and alkaline phosphatase, as well as characteristic lesions on computed tomography, nuclear magnetic resonance and ultrasonographic findings and positive blood culture in one patient. The antifungal treatment was successful in one patient only. Two patients died due to progression of leukaemia.

CONCLUSION

If leukaemia patient in remission after chemotherapy develops a prolonged fever of unknown origin, hepatosplenic candidiasis has to be considered and all efforts should be done to diagnose it. The diagnosis is based on clinical presentation and imaging techniques. The positive cultures of fungi are not usually possible and are not mandatory. The antifungal treatment may be prolonged, sometimes 2 to 3 months or even more.

Acute renal infarction due to fungal vascular invasion in disseminated candidiasis

Disseminated candidiasis occurs almost exclusively in leukemic patients recovering from neutropenia. Although renal involvement can be a sequela of disseminated candidiasis, acute renal infarction secondary to Candida invading the renal vasculature has not previously been reported. Our patient, who was being treated for acute myelogenous leukemia, developed complete obstruction of the right renal vessels during the course of 36 hours as documented by serial renal ultrasound scans with Doppler investigation of the vasculature. Histopathologic examination of the nephrectomy specimen revealed complete infarction of the kidney secondary to Candida spp. infiltrating the parenchyma and occluding the hilar vessels.

Adjuvant corticosteroid therapy for chronic disseminated candidiasis

BACKGROUND

Chronic disseminated candidiasis (CDC) is typically observed during neutrophil recovery in patients with acute leukemia and requires protracted antifungal therapy.

OBJECTIVE

Our objective was to document the efficacy and tolerance of corticosteroid therapy (CST) in patients with symptomatic CDC, including those who experienced fever and abdominal pain despite ongoing antifungal therapy.

METHODS

We performed a retrospective, multicenter study involving 10 pediatric and adult patients who experienced ongoing symptomatic CDC despite receipt of appropriate antifungal therapy for whom adjuvant oral CST was initiated.

RESULTS

All cases of CDC were proven or probable, as determined on the basis of the European Organization for Research and Treatment of Cancer-Mycosis Study Group definition criteria, and occurred in patients with leukemia. CDC-attributable clinical symptoms resolved with CST, which was started a mean of 33.8 days after antifungal therapy had been initiated. Fever and abdominal pain disappeared a median of 4-5 days, and serum fibrinogen and C-reactive protein levels returned to normal values within 14-30 days. The median duration of hospitalization after CST initiation was 8.8 days. Hepatosplenic microabscesses decreased or disappeared within a mean period of 107 days (range, 30-210 days). No relapses of CDC were observed during a median duration of follow-up of 6.5 years (range, 4-9 years).

CONCLUSIONS

In children and adults who experience persistently symptomatic CDC despite ongoing receipt of antifungal therapy, CST involving a prednisone equivalent at a dosage of > or =0.5 mg/kg per day for at least 3 weeks is associated with a prompt resolution of symptoms and of inflammatory response. These findings support the pathophysiological hypothesis that CDC belongs to the spectrum of fungus-related immune reconstitution inflammatory syndrome.

Successful treatment of refractory chronic disseminated candidiasis after prolonged administration of caspofungin in a child with acute myeloid leukemia

This report documents the clinical activity of caspofungin in a 13-year-old girl with acute myeloid leukemia (AML) and chronic disseminated candidiasis (CDC), refractory to amphotericin B and fluconazole. Caspofungin was started at 50 mg/d resulting in a temporary response. With no further clinical improvement and radiological progress after 2 months of therapy, the dose of caspofungin was increased to 100 mg/d, leading to a sustained clinical response. Therapy was given for a total of 12 months and had no attributable adverse effects. This approach resulted in successful treatment of refractory CDC with caspofungin.

Invasive Fungal Infections in Patients with Acute Leukemia

Invasive fungal infections, a serious problem among cancer patients, are increasing in incidence, and can cause morbidity and mortality. Such infections may hinder additional treatment, especially for patients with leukemia. We report here our experiences in the management of invasive fungal infection in patients with acute leukemia. A total of 18 patients were enrolled in the study: 12 had microabscesses of the liver and/or spleen and/or kidneys; four had sinonasal infections; and two had pulmonary infections. Most of the patients (88.9%) received amphotericin B during treatment for fungal infection. Thirteen patients achieved complete response without evidence of fungal infection in follow-up. In the study, there were 11 mortalities, including five patients who died during therapy and six who later died as a result of relapse or refractoriness of the leukemia. We suggest that many patients may have a good response to antifungal therapy, and that fungal infection does not have to preclude additional chemotherapy after proper management. The state of the underlying disease has a strong impact on outcome.

Invasive Candidiasis in Immunocompromised Hospitalized Patients

The frequency of infections by Candida species is increasing worldwide, with candidemia representing the fourth most common bloodstream infection in the U.S. The risk of infection is especially high in the immunocompromised, hospitalized patient. The treatment of and prophylaxis for Candida infection have led to the emergence of resistant species and the acquisition of resistance in previously susceptible species. Current therapeutic options include amphotericin B and its lipid compounds, fluconazole, itraconazole, voriconazole, and caspofungin. Research is focusing on better diagnostics and the evaluation of strategies such as prophylaxis in high-risk hosts and pre-emptive therapy.

Chronic disseminated candidiasis in patients with acute leukemia: emphasis on diagnostic definition and treatment

BACKGROUND

Chronic disseminated candidiasis (CDC) is a form of invasive fungal infection that occurs most commonly in patients with acute leukemia treated with chemotherapy. Recent studies have provided evidence for diagnostic alternatives to invasive procedures and more therapeutic options for the management of this complication. In order to put diagnostic criteria and methodological approach to the disease into the perspective of developing strategies for therapy, all relevant studies published in the English literature over the last 30 years were examined.

MATERIALS AND METHODS

The English-language articles located through MEDLINE (1966 to present) and from selected bibliographies.

RESULTS

There is increased recognition of CDC as complication of treatment with chemotherapy in patients with acute leukemia. Liver biopsy may not always be revealing or feasible to perform in some patients. Among the imaging modalities, magnetic resonance imaging has obtained preeminence as a non-invasive tool for the diagnosis of hepatosplenic fungal infections. Administration of amphotericin B (Amp B) in relatively large cumulative doses is needed to ensure appropriate control of the infection and prevention of future relapse. Patients intolerant of, or refractory to conventional Amp B have been successfully salvaged using fluconazole or lipid formulations of Amp B. A constellation of clinical, laboratory and radiologic parameters should be used to determine response and efficacy of therapy. There is sufficient evidence to support the safety and feasibility of continuing chemotherapy for acute leukemia in conjunction with antifungal treatment in patients diagnosed with CDC.

CONCLUSION

The development of CDC in patients with acute leukemia does not preclude further chemotherapy or constitute contraindication for bone marrow transplantation. Knowledge of the course and pattern of evolution of the disease and adopting aggressive therapeutic approach will likely reduce the morbidity and mortality from this complication.

The diagnosis of hepatosplenic candidiasis by DNA analysis of tissue biopsy and serum

Hepatosplenic candidiasis is traditionally diagnosed by blood culture, magnetic resonance imaging (MRI), and histological analysis. The limitations of these methods include: low sensitivity (blood culture) and failure to isolate the organism (MRI/histology). This report describes a case of hepatosplenic candidiasis diagnosed by simultaneous polymerase chain reaction (PCR) analysis of liver biopsy and serum. PCR of biopsy and/or serum may offer a sensitive and specific diagnostic test for hepatosplenic candidiasis. Candida species can be identified, which helps guide antifungal chemotherapy, an important aspect in this difficult to treat infection.

Hepatosplenic fungal infection in patients with acute leukemia in Taiwan: incidence, treatment, and prognosis

Nosocomial fungal infection increases gradually and has become the leading pathogen at National Taiwan University Hospital since 1993. From January 1995 through May 2002, hepatosplenic fungal infection (HSF) was diagnosed in 37 (7.4%) of the 500 adult patients with acute leukemia who received chemotherapy at this hospital. There was no significant difference in the incidence of HSF between the patients with acute myeloid leukemia and those with acute lymphoblastic leukemia, or between the patients treated with high-dose chemotherapy and those with conventional or low-dose chemotherapy. Candida tropicalis was the leading pathogen, followed by Candida albicans. The computed tomography scan showed multiple hypodense lesions in the liver (89%), spleen (70%), and kidney (27%). Eighteen patients were initially treated with fluconazole and 19 with amphotericin B. Nineteen patients received the planned chemotherapy after the diagnosis of HSF. Among them, eight patients underwent hematopoietic stem cell transplantation and seven patients survived more than 100 days post-transplantation; none of these patients had relapse of prior HSF. Twenty-three patients (62%) died during a median follow up of 10 months, but only seven died due to HSF. In conclusion, a substantial percentage of patients with acute leukemia acquired HSF after chemotherapy and carried high mortality. However, HSF itself is not a contraindication for subsequent chemotherapy and hematopoietic stem cell transplantation.

Analysis of factors related to the occurrence of chronic disseminated candidiasis in patients with acute leukemia in a non-bone marrow transplant setting: a follow-up study

BACKGROUND

Chronic disseminated candidiasis (CDC) is a serious complication of treatment in patients with acute leukemia. Although some general risk factors are known to predispose to systemic fungal infections, few studies have addressed the relevance of certain clinical and laboratory features in patients with CDC.

PATIENTS AND METHODS

To define a subset of patients at high risk for CDC, the authors evaluated the demographics and clinical and laboratory characteristics of 423 patients with acute leukemia. Patients who had bone marrow transplant before the diagnosis of CDC were excluded from the analysis. The diagnosis of CDC was based on blood cultures, liver biopsy, and imaging studies. The authors conducted 2 separate regression analyses on 3 subsets of patients: patients without documented candidiasis (n = 374), patients with CDC (n = 23), and patients with candidemia (n = 26).

RESULTS

According to multivariate analysis, younger age (P = 0.009; odds ratio [OR], 1.96; 95% confidence interval [CI], 1.72-2.99), duration of neutropenia of 15 days or longer (P = 0.0003; OR, 11.7; 95% CI, 3.04-45.1), and use of prophylactic quinolone antibiotics (P = 0.039; OR, 3.85; 95% CI, 1.11-13.4) emerged as independent factors related to the development of CDC in patients with acute leukemia. The presence of severe mucositis, colonization with Candida, and administration of high-dose ara-C were statistically significant parameters in univariate analysis only (P = 0.0001, P = 0.003, and P = 0.058, respectively).

CONCLUSIONS

On the basis of the results of this investigation, it is possible to define a subset of patients with acute leukemia at very high risk for CDC. Because of the morbidity and mortality of this infection, a targeted prophylactic approach may be more effective and less costly than the random administration of antifungal agents.

Infectious morbidity in critically ill patients with cancer

Infection frequently complicates the course of cancer treatment and often adversely affects the outcome. Patients have a greater tendency for acquiring infections caused by opportunistic microorganisms. Agents with low virulence potential may lead to invasive and often life-threatening infections because of altered host immune function. The immune dysfunction may be caused by the underlying malignancy, by antineoplastic chemotherapy, or by invasive procedures during supportive care.

Progressive reduction in treatment-related deaths in Medical Research Council childhood lymphoblastic leukaemia trials from 1980 to 1997 (UKALL VIII, X and XI)

In the last 20 years, the survival rate for children with acute lymphoblastic leukaemia (ALL) has markedly improved, largely owing to a decrease in relapses. However, children still die from complications of treatment and these are potentially preventable. We have analysed data from three large consecutive national protocols for ALL from 1980 to 1997 [Medical Research Council United Kingdom ALL (MRC UKALL) trials VIII, X and XI] to compare the incidence and causes of treatment-related deaths (TRD). The percentage of TRD has fallen from 9% to 2% (UKALL VIII to XI), largely as a result of a decrease in fatal infections. Deaths during induction have fallen from 3% to 1%, the main causes of death being bacterial, followed by fungal infection, while other causes, chiefly haemorrhage, have not declined. Remission deaths also decreased from 6% to 1%, particularly those deaths due to measles and pneumocystis carinii. More guidelines for surveillance and treatment of infections have been included within progressively more intensive protocols. Risk factor analysis showed increased TRD in patients with Down's syndrome, high leucocyte count and older age in UKALL XI. In contrast, the introduction of blocks of intensification was not associated with an increased death rate. While improved supportive care has reduced the incidence of TRD, there is still scope for further reduction by prompt treatment of suspected infection. Maintenance of herd immunity remains of vital importance in avoiding deaths from measles.

Hepatosplenic tuberculosis mimicking disseminated candidiasis in patients with acute leukemia

Two cases of hepatosplenic tuberculosis in patients with acute leukemia during or after chemotherapy following prolonged neutropenia are presented. Tuberculosis should be considered as one cause of hepatosplenic abscesses during prolonged neutropenia, especially in countries where the disease is endemic.

Hepatosplenic Candidiasis, its Treatment and Effect on Remission Status in Patients with Acute Leukaemia-a Report of Five Cases

Hepatosplenic candidiasis is an increasingly encountered complication of treatment of patients with acute leukaemia [[1] Clin. Infect. Dis. 24 (1997) 375]. Management is difficult as delay in further chemotherapy may allow relapse of the leukaemia while the infection may progress if chemotherapy is continued [[2] Anticancer Res. 19 (1999) 757]. We report five cases of suspected hepatosplenic candidiasis in a single haematology unit over a 30-month period. All patients were treated with oral fluconazole following intravenous amphotericin or liposomal amphotericin B lipid complex. Chemotherapy was withheld during treatment of infection. Two patients remain in haematological remission despite suboptimal therapy for their leukaemia. One patient died from progressive fungal infection, 1 patient of cardiac disease and 1 patient has had recent relapse of their leukaemia. We demonstrate that hepatosplenic candidiasis may be treated with oral fluconazole while chemotherapy is discontinued and also suggest that this infection or its treatment may have had a beneficial immunomodulatory affect on the leukaemic process in the surviving patients.