Disseminated fusariosis in immunocompromised children: a case series and review of literature

In the era of antifungal prophylaxis for cancer patients, Fusarium genus has become the second leading cause of invasive fungal infections and mortality in this group of patients. The intrinsic resistance to antifungal agents and the patient's risk factors are the most important variables for prognosis and survival. Currently, the use of monotherapy in comparison to combined antifungal treatment information is scarce. In this report, we present a series of three cases of children with acute lymphoblastic leukemia and disseminated fusariosis categorized according to the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG). Furthermore, we present a current literature review focused on treatment using monotherapy or combined antifungal treatment.

Long-term survival after cord blood transplantation for acute myeloid leukemia complicated with disseminated fusariosis

Fusariosis is a critical infectious complication that can develop in immunocompromised hosts, mainly under conditions of prolonged neutropenia, and is often disseminated and associated with a high mortality rate. Disseminated fusariosis developing during the course of hematopoietic stem cell transplantation (HSCT) is a critical condition, and there have been few reports of successful treatment of cases complicated with fusariosis before HSCT. Here, we present a case of acute myeloid leukemia (AML) with the development of fungal endophthalmitis during chemotherapy. Vitrectomy was performed and Fusarium solani infection was confirmed by vitreal culture. The infection was also disseminated to the lung, triceps, and spleen. The splenic lesions disappeared with the administration of antifungal agents, and residual lesions in the lung and triceps were surgically resected. After two courses of consolidation chemotherapy, the patient received cord blood transplantation (CBT) twice because of graft failure in the first transplantation. Antifungal agents were administered continuously during chemotherapy and transplantation. Although Fusarium sinusitis developed after neutrophil engraftment, it was well controlled by surgical resection. Thereafter, the patient has been well without recurrence of fusariosis for more than 2 years since transplantation. A combination of continuous administration of antifungal agents and vigorous surgical intervention may be important for management of disseminated fusariosis in the setting of HSCT.

Disseminated fusariosis with ecthyma gangrenosum-like lesions in a refractory acute myeloid leukemia patient

Background and Purpose

Fusarium species is an opportunistic mold that causes disseminated infections in immunocompromised patients. Given the high mortality rate of this infection, it is important to make a definite diagnosis when encountering suspected cases.

Case report

Herein, we presented a 35-year-old man diagnosed with acute myeloid leukemia with a prolonged febrile neutropenic period and ecthyma gangrenosum-like lesions, along with fungemia and disseminated fusariosis. The patient died despite receiving combination therapy, perhaps due to the nonrecovery of neutrophil.

Conclusion

Ecthyma gangrenosum-like lesions due to disseminated fusariosis might be easily misdiagnosed. Consequently, more attention should be paid to the cutaneous lesions in immunocompromised patients.

Report of three new cases

BACKGROUND

Fungi of the genus Fusarium are primarily plant pathogens and saprobes that produce disseminated infections in immunologically deficient humans. After aspergillosis, disseminated fusariosis is the second most common cause of invasive infection by filamentous fungi in patients with hematologic malignancies or those undergoing transplants of hematopoietic progenitors.

AIMS

Disseminated fusariosis (DF) is considered an extremely rare infection and has reached a stable incidence rate, but its high mortality rate and the lack of an optimal management protocol have raised increasing interest in this mycosis.

METHODS

We present three cases of DF produced by Fusarium oxysporum species complex, Fusarium solani species complex and the highly unusual Fusarium dimerum in patients with advanced hematological malignancies diagnosed in our hospital between 2007 and 2011. The species level identification of the Fusarium isolates was established by sequencing their TEF1 gene.

RESULTS

The isolates showed low susceptibility to most of the antifungal agents analyzed, except that observed for F. dimerum to amphotericin B (AmB) and terbinafine, and F. oxysporum species complex to AmB. Interestingly, the strain of F. solani species complex exhibited high MIC values for AmB and voriconazole, notwithstanding these drugs were used for treatment with good results. Other relevant aspects to be considered in the treatment of DF are surgically cleaning foci of infection, withdrawing presumably contaminated catheters and recovery from neutropenia.

CONCLUSIONS

The prevention of infection in colonized patients, the maintenance of a high level of diagnostic suspicion for early diagnosis, and the combined, vigorous and prolonged use of L-AmB and voriconazole are essential to decrease the mortality rate of this devastating infection.

Ecthyma Gangrenosum-like Lesions in a Febrile Neutropenic Patient with Simultaneous Pseudomonas Sepsis and Disseminated Fusariosis

Fusarium spp. is an opportunistic mold that causes disseminated infections in immunocompromised patients. It is important to make a definite diagnosis because of high mortality rates. We present the case of a 27-year-old pregnant woman diagnosed with acute myeloid leukemia with a prolonged febrile neutropenic period. She developed ecthyma gangrenosum-like lesions and simultaneously had Pseudomonas bacteremia and disseminated fusariosis. Histopathological and microbiological features of skin lesions had a critical role in differential diagnosis. Ecthyma gangrenosum-like lesions due to disseminated fusariosis might be easily misdiagnosed as lesions associated with Pseudomonas unless tissue cultures and histopathological examinations are performed.

Conflict of interest:None declared.