An autopsy study of systemic fungal infections in patients with hematologic malignancies

Study on invasive aspergillosis using galactomannan enzyme immunoassay and determining antifungal drug susceptibility among hospitalized patients with hematologic malignancies or candidates for organ transplantation

The incidence of invasive aspergillosis (IA) has dramatically increased during the last decade. This infection is associated with high morbidity and mortality, ranging from 30% to 70%, especially in immunocompromised patients. Delay in diagnosis and treatment is usually associated with high mortality rates. This study was aimed to assess the diagnostic value of Galactomannan EIA (GM) for early diagnosis of aspergillosis in hospitalized patients with underlying conditions. Also, the antifungal drug susceptibility profiles of causative agents were investigated. In this descriptive cross-sectional study, during the period of 18 months starting from September 2017 until February 2019, 22 bronchoalveolar lavage (BAL) and 13 biopsies from infected sinuses were obtained from a total of 150 patients suffering from different types of hematologic malignancies. All the samples were subjected to microscopic examination and fungal culture. Also, serum specimens were obtained from all patients (n = 135). 22 serum and 17 BAL specimens were tested for the GM level. Fungal identified were confirmed through the PCR-sequencing of the β-tubulin gene. The susceptibility to amphotericin B, itraconazole, voriconazole, posaconazole, ravuconazole, and caspofungin was evaluated according to the Clinical and Laboratory Standards Institute document M38-A2 (CLSI M38-A2) broth microdilution protocol. The results showed that the incident rate of IA was 23.33% and 35 patients with IA (12 proven cases and 23 probable cases) were diagnosed according to the European Organization for Research and Treatment of Cancer and Mycoses Study Group criteria. The 35 patients with IA in the current study comprised 19 men (54.29%) and 16 women (45.71%) with the median age of 42 years. AML (31.5%) was documented as the most prevalent risk factor among our subjects with IA and Aspergillus flavus (65.7%) was the most prevailing causal agent in this study. Among patients with IA, ague (71%) and cough (60%) were the most common symptoms. In the present study, a sensitivity of 94% and a specificity of 98% was reported for GM ELISA in BAL specimens. Also, a sensitivity of 58% and a specificity of 98% was reported for GM ELISA in serum samples. Among 6 tested antifungal drugs, the lowest minimum inhibitory concentration (MIC) values were observed for posaconazole and ravuconazole which showed the range of 0.008-0.0062 μgml and 0.031-0.125 μgml, respectively. The current study has demonstrated that determining the value of GM investigation in BAL and serum specimens can be promising in early diagnosis of IA, also molecular identification of the agents causing IA and their antifungal susceptibility patterns are essential issues for the targeted antifungal therapy and outcome improvement of patients with this life-threatening disease.

Concurrent lung infections in patients with hematological malignancies and invasive pulmonary aspergillosis: how firm is the Aspergillus diagnosis?

BACKGROUND

Immunocompromised patients with hematological malignancies and/or recipients of hematopoietic stem cell transplants are constantly exposed to several fungal, bacterial, and viral respiratory pathogens.

METHODS

We retrospectively evaluated all patients with invasive pulmonary aspergillosis (IPA) and underlying hematological malignancies for the presence of concurrent, microbiologically documented pulmonary infections during a 5-year period (2005-2010).

RESULTS

We found 126 such patients that frequently had coinfections (49%) with respiratory pathogens other than Aspergillus species, with a higher rate in patients with probable IPA (53%) than in those with proven IPA (29%; P=0.038).

CONCLUSIONS

As the majority of patients with IPA in daily practice have probable IPA, often according to only the combination of positivity for serological biomarkers and radiological findings, our data may raise skepticism about both the certainty of IPA diagnosis and the evaluation of response to antifungals in a subset of these patients.

Invasive aspergillosis in developing countries

To review invasive aspergillosis (IA) in developing countries, we included those countries, which are mentioned in the document of the International Monetary Fund (IMF), called the Emerging and Developing Economies List, 2009. A PubMed/Medline literature search was performed for studies concerning IA reported during 1970 through March 2010 from these countries. IA is an important cause of morbidity and mortality of hospitalized patients of developing countries, though the exact frequency of the disease is not known due to inadequate reporting and facilities to diagnose. Only a handful of centers from India, China, Thailand, Pakistan, Bangladesh, Sri Lanka, Malaysia, Iran, Iraq, Saudi Arabia, Egypt, Sudan, South Africa, Turkey, Hungary, Brazil, Chile, Colombia, and Argentina had reported case series of IA. As sub-optimum hospital care practice, hospital renovation work in the vicinity of immunocompromised patients, overuse or misuse of steroids and broad-spectrum antibiotics, use of contaminated infusion sets/fluid, and increase in intravenous drug abusers have been reported from those countries, it is expected to find a high rate of IA among patients with high risk, though hard data is missing in most situations. Besides classical risk factors for IA, liver failure, chronic obstructive pulmonary disease, diabetes, and tuberculosis are the newly recognized underlying diseases associated with IA. In Asia, Africa and Middle East sino-orbital or cerebral aspergillosis, and Aspergillus endophthalmitis are emerging diseases and Aspergillus flavus is the predominant species isolated from these infections. The high frequency of A. flavus isolation from these patients may be due to higher prevalence of the fungus in the environment. Cerebral aspergillosis cases are largely due to an extension of the lesion from invasive Aspergillus sinusitis. The majority of the centers rely on conventional techniques including direct microscopy, histopathology, and culture to diagnose IA. Galactomannan, β-D glucan test, and DNA detection in IA are available only in a few centers. Mortality of the patients with IA is very high due to delays in diagnosis and therapy. Antifungal use is largely restricted to amphotericin B deoxycholate and itraconazole, though other anti-Aspergillus antifungal agents are available in those countries. Clinicians are aware of good outcome after use of voriconazole/liposomal amphotericin B/caspofungin, but they are forced to use amphotericin B deoxycholate or itraconazole in public-sector hospitals due to economic reasons.

Cryptococcosis-a review of 13 autopsy cases from a 54-year period in a large hospital

From 1952 to 2005, 13 cases of cryptococcosis confirmed by postmortem examination were diagnosed in autopsy material from the University Hospital in Hradec Králové, the Czech Republic. Histologically, Cryptococcus was found in multiple organs (brain and spinal cord, lungs, lymph nodes, spleen, bone marrow, liver, kidneys and adrenal glands). The lungs and CNS were the organs most often involved. Only in two cases was the diagnosis of cryptococcal infection established during the patient's lifetime, in both presenting clinically as meningitis, with positive result of CSF cultivation. Data and issues of diagnostics and treatment of cryptococcosis are discussed.

Autopsy-proven causes of death in lungs of patients immunocompromised by secondary interstitial pneumonia

PURPOSE

To present the more frequent associations found in autopsies of immunocompromised patients who developed secondary interstitial pneumonia as well as the risk of death (odds ratio) in having specific secondary interstitial pneumonia according to the cause of immunocompromise.

METHOD

From January 1994 to March 2004, 17,000 autopsies were performed at Hospital das Clínicas, São Paulo University Medical School. After examining the pathology report review, we selected 558 of these autopsies (3.28%) from patients aged 15 years or more with primary underlying diseases who developed radiologically diffuse infiltrates of the lung during their hospital course and died after secondary interstitial pneumonia (bronchopneumonia, lobar pneumonia, interstitial pneumonia, diffuse alveolar damage, pulmonary recurrence of underlying disease, drug-induced lung disease, cardiogenic pulmonary edema, or pulmonary embolism). Histology slides were reviewed by experienced pathologists to confirm or not the presence of secondary interstitial pneumonia. Statistical analysis included the Fisher exact test to verify any association between histopathology and the cause of immunocompromise; a logistic regression was used to predict the risk of death for specific histological findings for each of the independent variables in the model.

RESULTS

Secondary interstitial pneumonia was histologically represented by diffuse interstitial pneumonitis ranging from mild nonspecific findings (n = 213) to a pattern of diffuse alveolar damage (n = 273). The principal causes of immunocompromise in patients with diffuse alveolar damage were sepsis (136 cases), neoplasia (113 cases), diabetes mellitus (37 cases), and transplantation (48 cases). A high risk of death by pulmonary edema was found for patients with carcinoma of colon. Similarly, in patients with lung cancer or cachexia, A high risk of death by bronchopneumonia (OR = 3.6; OR = 2.6, respectively) was found. Pulmonary thromboembolism was associated with an appreciable risk of death (OR = 2.4) in patients with arterial hypertension. The risk of death was also high in patients presenting hepatic cancer (OR = 2.5) or steroid therapy (OR = 2.4) who developed pulmonary hemorrhage as the histological pattern of secondary interstitial pneumonia . The risk of death by lung metastasis was also elevated (OR = 1.6) for patients that were immunosuppressed after radiotherapy.

CONCLUSION

Patients with secondary immunosuppression who developed secondary interstitial pneumonia during treatment in hospital should be evaluated to avoid death by diffuse alveolar damage, pulmonary edema, bronchopneumonia, lung hemorrhage, pulmonary thromboembolism, or lung metastasis. The high-risk patients are those immunosuppressed by hematologic disease; those under steroid treatment; or those with colon or hepatic carcinoma, cachexia, or arterial hypertension.

Salvage Therapy of Refractory Chronic Disseminated Candidiasis in a Patient with Acute Myeloid Leukaemia and Secondary Prophylaxis During Allogeneic Stem Cell Transplantation

We report on the treatment course of a 27-year-old male patient with acute myeloid leukaemia M1 and chronic disseminated candidiasis. After induction chemotherapy, the patient developed oesophageal candidiasis while participating in a voriconazole vs. placebo prophylaxis trial. He was then switched to oral fluconazole 400 mg q.i.d. After 6 days of futile fluconazole therapy he was switched to caspofungin 50 mg q.i.d. Caspofungin dose was later increased to 100 mg q.i.d after disseminated candidiasis with involvement of lung, spleen and liver was diagnosed. Following 63 days of caspofungin without resolution of symptoms, i.e. being persistently febrile, and emergence of soft tissue Candida abscesses, he was included into a trial allowing compassionate use of posaconazole as salvage therapy for refractory invasive fungal infections. Symptoms rapidly resolved under posaconazole 200 mg q.i.d. treatment and the patient was able to undergo allogeneic haematopoietic stem cell transplantation on secondary prophylaxis with posaconazole.

Pulmonary Complications in Adult Blood and Marrow Transplant Recipients

STUDY OBJECTIVE

To describe the pulmonary findings at autopsy of blood and bone marrow transplant (BMT) recipients.

DESIGN

Retrospective.

SETTING

An academic medical center.

PATIENTS

Seventy-one deceased adult BMT recipients.

INTERVENTIONS

None.

MEASUREMENTS

Antemortem and postmortem pulmonary findings.

RESULTS

The transplants were allogeneic in 39 patients (55%), with a peripheral stem cell source in 43 patients (61%). Death occurred at a median of 1.30 months after transplant. Ninety-six pulmonary complications were noted in 63 patients (89%): 27 infectious (bacterial bronchopneumonia, n = 13; pulmonary aspergillosis, n = 11; cytomegalovirus pneumonia, n = 2; and Candida bronchopneumonia, n = 1) and 69 noninfectious (diffuse alveolar damage, n = 35; diffuse alveolar hemorrhage [DAH], n = 10; amyloidosis, n = 9; pulmonary embolism, n = 5; lymphoma/leukemia, n = 4; bronchiolitis obliterans, n = 2; bronchiolitis obliterans organizing pneumonia, n = 1; pulmonary alveolar proteinosis, n = 1; aspiration pneumonia, n = 1; and acute and organizing pneumonia, n = 1). Twenty-seven of the 96 complications (28%) were diagnosed antemortem. Infectious complications were more likely to be diagnosed antemortem compared to noninfectious complications (48% vs 20%, p = 0.006). Six of the 13 patients with bronchopneumonia (46%), 5 of the 11 patients with pulmonary aspergillosis (45%), and 7 of the 8 patients with DAH (88%) at autopsy were not receiving treatment for these conditions at the time of death. Ten patients being treated for suspected pulmonary aspergillosis, 7 patients treated for suspected pulmonary cytomegalovirus infection, 22 patients treated for suspected bacterial pneumonia, 2 patients treated for suspected Pneumocystis carinii pneumonia, and 12 patients treated for DAH at the time of death had no evidence of these conditions at autopsy. The most common immediate cause of death was respiratory failure (n = 37, 52%).

CONCLUSIONS

Pulmonary complications, the majority not diagnosed antemortem, are the most common cause of death in BMT recipients. As the result of underdiagnosis, BMT recipients may not receive appropriate therapy for potentially treatable pulmonary complications.

Aspergillus niger infection in patients with haematological diseases: a report of eight cases. Fallbericht. Aspergillus niger-Infektionen bei Patienten mit hamatologischen Erkrankungen

In this paper we analysed clinical, laboratory characteristics and outcome of patients with haematological diseases who developed an Aspergillus niger infection, in a multicentre study involving 14 Italian Haematological Divisions during a 10-year period. The study recorded 194 consecutive microbiologically documented aspergilloses, eight of which (4%) were due to A. niger, and were observed only in five of the participating centres. The primary localization of infection was lung in seven cases and paranasal sinus in one case. Seven patients died at the end of follow-up. The death was mainly attributable to A. niger progression in six of them. Our study that collected the largest number of cases of A. niger infection in haematological malignancies confirms that this infrequent complication is characterized by a high mortality rate.

Randomized trial of fluconazole versus low-dose amphotericin B in prophylaxis against fungal infections in patients undergoing hematopoietic stem cell transplantation

Over the past decade, invasive fungal infections have become an increasingly important problem in patients undergoing hematopoietic stem cell transplantation (HSCT). The optimal approach for prophylactic antifungal therapy has yet to be determined. To resolve this issue, we performed a prospective randomized study to compare the efficacy of fluconazole (FL) versus low-dose amphotericin B (AmB) in preventing fungal infections during the first 100 days after HSCT. Patients undergoing allogenic or autologous HSCT were randomized to receive fluconazole 200 mg/day PO or amphotericin B 0.2 mg/kg/day IV beginning 1 day prior to commencement of conditioning regimen and continuing until engraftment, drug-associated toxicity was suspected, or systemic fungal infection was suspected or proven. High-dose amphotericin B (0.5-1.0 mg/kg/day) was started for patients with suspected or proven fungal infections. From January 1993 to December 1998, a total of 186 patients were enrolled into the trial, with 100 receiving FL and 86 receiving AmB. Eighty (43%) patients were removed from prophylaxis for persistent fever despite broad-spectrum antibacterial therapy or suspected fungal infections (FL 46 vs. AmB 34, P > 0.05). The incidence of proven fungal infections (FL 12% vs. AmB 12.8%), suspected fungal infections (FL 4% vs. AmB 2.3%), superficial fungal infections (FL 1% vs. AmB 4.6%) did not show any significant difference. The survival at 100 days post transplant was similar between the 2 groups (FL 78% vs. AmB 70%, P = 0.254). Death attributable to fungal infections was similar in both groups (6% vs. 7%, P > 0.05). We conclude that fluconazole is as effective as low-dose amphotericin B in prophylaxis against fungal infections in patients undergoing hematopoietic cell transplantation.

Hansenula anomala outbreak at a surgical intensive care unit: a search for risk factors

During a 5-month period, Hansenula anomala (H. anomala), an opportunistic fungus, caused an outbreak of infections in eight adult patients treated at a surgical intensive care unit (ICU). The source of the infections and route of transmission could not be identified. A case-control study included 32 patients treated simultaneously at the surgical ICU. Univariate analysis pointed to the following significant risk factors: blood alkalosis, reduced urea, duration of hospitalization, bacteremia and colonization with Pseudomonas aeruginosa, and an APACHE II score >17 (during bacteremia or fungemia). The stepwise logistic regression multivariate analysis showed only the duration of blood alkalosis to be significant in case patients.

Incidence of endomycoses in autopsy material

From 1970 to 1993, 93 endomycoses confirmed by postmortem examination were diagnosed in the autopsy material of the Berlin Charité, a large hospital with an average of 1,500 Hospital beds and maximum medical care. These comprised 51 candidoses (54.8%), 24 aspergilloses (36.5%), five cryptococcoses (5.4%), one zygomycosis, one trichosporosis and one coccidioidomycosis. This corresponded to 0.7% of the 13,275 deceased persons autopsied during this period. The frequency of autopsy was 85.3%. In 3,770 cases (2,418 adults and 1,352 children), brain dissection was performed. An adequate clinical putative diagnosis was made in only six out of 28 patients (18 adults, 10 children) with histologically confirmed cerebral mycosis: 11 candidoses (39.3%), 10 aspergilloses (35.7%) five cryptococcosis (17.8%), one trichosporosis and one coccidioidomycosis. About 80% of the mycoses of the CNS thus remained undetected while the patients were alive. The observations made in the present paper underscore the importance of clinical autopsy in endomycoses.

Autopsy pathology of pediatric posttransplant lymphoproliferative disorder

OBJECTIVES

Posttransplant lymphoproliferative disorder (PTLD) causes significant morbidity and mortality, is related to Epstein-Barr virus (EBV) infection, and is more common in children than in adults. We reviewed autopsies of children who died with PTLD to compare postmortem with antemortem PTLD histology, to assess the extent of PTLD, to document associated pathology, and to identify cause of death.

METHODS

Postmortem examinations were performed on 7 patients after bone marrow (n = 3) or liver (n = 4) transplant. PTLD was classified histologically as hyperplasia or lymphoma. In situ hybridization for EBER1 messenger RNA was performed on tissue samples from all cases. EBV serologies were used to categorize infections as negative, primary, or reactive.

RESULTS

PTLD was diagnosed in 5 children 12 to 35 (mean: 22) days before death, and 1.5 to 4 (mean: 3) months after transplant; PTLD was diagnosed in 2 cases at autopsy 2.5 and 4 months after transplant. Postmortem PTLD histology resembled antemortem histology; 5 PTLDs were lymphoma, 1 was hyperplasia, and 1 contained both lymphoma and hyperplasia. EBER1 messenger RNA was detected in 6 B-cell PTLDs, including lesions from patients who did not have EBV serology that indicated active infection. Complete autopsy of 4 patients who died with biopsy-proven PTLD revealed widely disseminated disease, and lymph node, brain, gastrointestinal tract, and kidney were involved in all 4 patients. Cases diagnosed at autopsy were 1 widely disseminated PTLD that had been suspected but not proven antemortem, and 1 PTLD confined to abdominal lymph nodes that was not suspected antemortem. Severe organ dysfunction (renal failure, gastrointestinal hemorrhage) was caused by massive PTLD infiltration in 2 patients. The conditions other than PTLD that contributed to morbidity and death were organ infection (5 cases), infarcts (4 cases), and diffuse alveolar damage (3 cases).

CONCLUSIONS

PTLD may occur within weeks after transplant in children. The distribution of PTLD comprises a spectrum from localized and subclinical to widely disseminated and symptomatic. PTLD may cause demise quickly after the onset of signs and symptoms, through massive organ infiltration or associated conditions, such as diffuse alveolar damage. EBV serology may not accurately reflect the presence or extent of PTLD. Autopsy studies of transplant patients are necessary to identify the true incidence, natural history, and response to treatment of PTLD.

Oral antifungals as prophylaxis in haematological malignancy

In the standard treatment of patients with haematological malignancy, immunosuppressive therapy produces prolonged periods of neutropenia and mucositis, which increase the risk of systemic fungal infection. In allogeneic bone marrow transplantation, this risk extends well beyond the period of neutropenia when graft-versus-host disease, and its treatment, result in prolonged lymphocytopenia. Various agents are used for antifungal prophylaxis and treatment but all have limitations: amphotericin B is restricted by the need for intravenous infusion and the occurrence of adverse events, fluconazole by its narrow spectrum of activity and the emergence of fluconazole-resistant fungi and itraconazole capsules by erratic absorption. Oral administration of antifungals has clear advantages in prophylaxis and an important current strategy is to maximize the extent and reliability of the oral bioavailability of antifungal agents. Mucositis is the main obstacle for success of strategies based on oral delivery. In this review, the ability of these new oral formulations to deliver sufficient antifungal prophylaxis is evaluated.

Assessing risk factors for systemic fungal infections

The incidence of invasive fungal infection has increased in recent years. Most infections are caused by Candida albicans and Aspergillus spp. but the emergence of other fungal infections is changing the spectrum of disease. Immunosuppression and breakdown of anatomical barriers such as the skin are the major risk factors for fungal infections. Health care workers encounter at-risk patients in various settings, including AIDS clinics and intensive care, transplantation and oncology units. Patients with prolonged and deep neutropenia (haematological malignancy patients) are most at risk and are therefore most likely to receive prophylactic therapy. Practical measures can be taken to avoid exposing the patient to fungi (air filtration, regular hand washing, avoiding plants and flowers) and antifungal agents can be administered to prevent systemic fungal infection. Most fungal infections have non-specific symptoms; this makes recognition of the signs and symptoms of the disease important but also makes diagnosis difficult and empirical treatment necessary. Some antifungal agents have limitations but new formulations will improve therapy and play a key role in future antifungal strategies.

A double-blind comparison of fluconazole and nystatin in the prevention of candidiasis in patients with leukaemia. Antifungal Prophylaxis Study Group

In this multicentre, randomised, double-blind study, the safety and efficacy of oral fluconazole (200 micrograms/day) and nystatin suspension (6,000,000 IU/day) for the prevention of fungal infections were compared in patients with leukaemia undergoing remission induction chemotherapy. Antifungal prophylaxis was initiated at the time chemotherapy was started and continued throughout the hospital stay or the period of neutropenia to a maximum of 42 days. Prophylaxis was successful (no evidence of fungal infection or fever of unknown origin unresponsive to antibiotics) in 38 of 56 (68%) fluconazole-treated and 25 of 53 (47%) nystatin-treated patients (P = 0.03). 2 patients (4%) in the fluconazole group and 6 (11%) patients in the nystatin group developed systemic fungal infections (P = 0.15). The overall frequency of adverse events was similar among fluconazole-treated (29%) and nystatin-treated (32%); most events in both treatment groups involved the gastrointestinal tract. These results indicated fluconazole was more effective than nystatin in preventing Candida infections in patients with leukaemia; fluconazole was well tolerated.

Identification of Candida species by randomly amplified polymorphic DNA fingerprinting of colony lysates

We have characterized a method that produces simple yet diagnostic fingerprints that are unique to isolates of Candida species. DNA from individual colonies can be amplified from crude single-colony lysates. Randomly amplified polymorphic DNA (RAPD) fingerprints generated from a single primer correctly identified the species of most (>98%) of the isolates identified with CHROMagar Candida plates as non-Candida albicans Candida species. RAPD fingerprints were much more informative than the plates, since they distinguished between all tested species and required less time. Most (91%) of these identifications agreed with those assigned by API 20C tests. In almost every incident of species identity mismatch, electrophoretic karyotyping showed that the RAPD fingerprint was correct. This underscores the improved objectivity and reliability of this method over those of conventional diagnostic tools. The identities of approximately 30% of C. albicans isolates identified in clinical laboratories by positive germ tube tests are not verified by either testing on CHROMagar Candida plates or RAPD fingerprinting. Data suggest that clinical isolates conventionally identified as C. albicans in clinical settings are heterogeneous, consisting of both misidentified and atypical yeasts. RAPD fingerprints obtained from primary culture plate colonies allows for rapid, highly accurate determinations of Candida species, hence permitting earlier selection of appropriate antifungal agents in the clinical setting.

Fatal diffuse invasive gastrointestinal candidiasis masking as ileus after bone marrow transplantation

High-dose cytotoxic chemotherapy has increased the incidence of candidal infections that make neutropenic patients very sick and may kill them. We report fatal invasive candidiasis involving the entire alimentary tract after autologous bone marrow transplantation in a young woman with breast cancer. Illustrated are the significance of fungal infections in this patient population, the potential for Candida albicans to invade the entire gastrointestinal tract, and the potential role of endoscopy in the early diagnosis of these often catastrophic infections. We also suggest that diffuse, invasive candidiasis should be considered in the differential diagnosis of ileus in the immunocompromised patient.

Clinical and laboratory diagnosis of invasive candida infection in neutropenic patients

Cancer patients, especially those with acute leukaemia, represent a group that has the greatest risk for deep fungal infection. Almost no cases were seen before the advent of modern chemotherapy, and prior to the availability of antibacterial agents, less than 5% of patients with acute leukaemia died of fungal infection. These infections are now responsible for 40% or more of the deaths at some institutions. Candida species continues to be the most common fungal pathogen. Rapid and specific diagnosis of invasive candiosis enabling early effective therapy is therefore an important measure for reducing mortality in patients. Here the current status of clinical and laboratory diagnosis of invasive candida infection in neutropenic patients is discussed and recommendations made as to future development programmes.