Multi-modality guided treatment with resolution of long lasting invasive aspergillosis and hormografiella species within immunocompromised host; a case history

Ref ID: 19417

Author:

L. F. Span, A. W. J. M. Glaudemans, J. P. Arends and
J. W. C. Alffenaar

Author address:

UMCG, Groningen, the Netherlands

Full conference title:

6th Trends in Medical Mycology 2013

Date: 11 October 2014

Abstract:

Objectives Invasive Hormografiella species in immunocompromised
patients are very rare and difficult to treat. The prognosis of these
patients is almost always dismal (90% mortality in literature). We
treated a patient with this type of fungal disease and used plasma
antifungal levels, inflammation markers (CRP), and imaging tech-
niques like PET-CT scans to guide the response of treatment. Further-
more, these parameters and techniques played an important role in
treatment changes. The objective of this complex case is to show
how different diagnostic tools can guide the clinician and provide a
higher chance of successful treatment of these patients.
Methods and results We treated a 58 years old male patient with
hairy cell leukemia (HCL) with weekly cladribine under adequate
antibacterial, antiviral, and antifungal prophylaxis. After a prolonged
period of pancytopenia, he developed neutropenic fever with cough-
ing and dyspnea with pleuritic chest pain at the left side for which
broad spectrum antibiotics were given. A chest x ray and subse-
quently high resolution ct scan revealed several lung nodules with
halo signs and pleural effusion. A galactomannan (GM) was positive
in serum (3.44), BAL fluid (lingual; 9.24), and pleural fluid (12.7).
Aspergillus PCR was positive and culture of BAL fluid revealed Hor-
mografiella spp., which is a filamentous non-Aspergillus mould
belonging to the class of Basidiomycetes (in this case: anamorph of
Coprinellus xanthothrix). This species was susceptible for all antifun-
gals, except for flucytosine. Voriconazole was started initially, subse-
quently ambisome, caspofungin, and also flucytosine were added
with adequate blood levels because of progressive fungal disease and
symptoms. Also G-CSF was added to improve neutrophilic counts,
which took about one month. Afterwards he was still moderate to
severe lymphocytopenic for almost 5 months. All therapeutic
changes were guided by symptoms, CRP, GM levels, and PET-CT
scans in time, as also masses were found in the thyroid gland and
between the left liver lobe and the spleen. After 5 months he was put on posaconazole with adequate plasma levels and was discharged
from the hospital. Eventually his GM and CRP normalized after
7 months of treatment. Unfortunately, his abdominal mass grew on
PET-CT scan, whereas the other masses decreased in size and activity
or resolved. An operative procedure with resection of this mass and
splenectomy was performed; a granulomatous inflammation with
hyphae was found, whereas the cultures were negative. After
2.5 years his antifungal treatment was stopped after his PET scan
became negative, and his IgG levels and CD4 counts had resolved.
His HCL is still in remission.
Conclusion Multi-modality diagnostics, especially PET-CT scanning,
have important impact in guidance of treatment of complex, long
lasting fungal disease, especially in prolonged immunocompromised
conditions

Abstract Number: p179

Conference Year: 2013

Link to conference website: NULL

New link: NULL

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