Background: Infection is a life-threatening complication for patients with leukaemia on chemotherapy.Fungal infection represents a particular problem for patients with AML undergoing chemotherapy. Aspergillus spp is a common environmental fungus, with spores in soil,air and plants.The most common mode of transmission is airborne,and the vast majority of invasive infections involve the lungs. Isolated Aspergillus spp infections causing appendicitis is rare, with only a few reported cases.
Clinical Case: A 7 year old boy presented with a short history of fever, sore throat and a petechial rash. His white cell count was 54 x109/L (96% blasts) and bone marrow biopsy confirmed acute myeloid leukaemia (AML). Two weeks after starting chemotherapy (and after ten days of profound neutropenia) the patient complained of symptoms consistent with appendicitis, confirmed on abdominal ultrasound scan. He did not respond to 48 hours of conservative management with intravenous antibiotics,and underwent an uneventful laparoscopic appendectomy.The appendix was macroscopically normal, but unusually there were features suggestive of fungal infiltration on histological analysis. He was treated with liposomal Amphotericin and Posaconazole,alongside antibiotics, while awaiting confirmation of the organism. After 17 days Aspergillus nidulans was confirmed via histological examination and subsequent polymerase chain reaction (18sPCR) of the appendix tissue. Antifungal treatment was rationalised to Posaconazoleat this time.The patient recovered well and was discharged 3 weeks post operatively, on oral Posaconazole.
Conclusions:This is a rare presentation of invasive fungal infection in a patient who was severely immunosuppressed. Recently,a collection of clinical features have been suggested to prompt consideration of fungal appendicitis. Namely,a patient who:
- Has a diagnosis of leukaemia Is undergoing chemotherapy
- Is profoundly neutropenic
- Has clinical features of appendicitis
- Is not responding to standard antibiotic therapy
Here, we demonstrate that a patient with risk factors for invasive fungal infection had a proven Aspergillus nidulans appendicitis which was successfully eradicated with Posaconazole. In patients with the above clinical features,consideration of a potential fungal cause of infection should prompt investigation (including molecular testing) and timely treatment.
Full conference title:
- ECCMID 29th (2019)