Risk assesment in the hemato-oncologic patient

Ref ID: 19352

Author:

M. S. Ruhnke and M. Hoenig

Author address:

Charite University Medicine, Berlin, Germany and Department
of Medicine, Section of Infectious Diseases, Medical University
Graz, Austria

Full conference title:

6th Trends in Medical Mycology 2013

Date: 11 October 2014

Abstract:

Immunocompromised patients, in particular those with cancer or
haematological diseases and allogeneic bone marrow/haematopoietic
stem cell transplant recipients (BMT/HSCT) carry a high risk for
invasive fungal infections (IFIs), which are mostly life-threatening.
Assessment of individual risk factors for invasive fungal diseases may
facilitate a more rapid and precise diagnostic approach in individual
patients. In addition, the type of immunosuppression, which predis-
poses the patient at risk, may relate to the type of underlying fungal
pathogen (e.g., Candida versus Aspergillus spp.). The most important
risk factors for invasive aspergillosis in patients with hematological
cancer are profound and sustained granulocytopenia (neutrophils
<500/lL for more than 10 days), allogeneic stem cell transplantion, intensive chemotherapy (e.g. high-dose cytosine-arabinosid), a his- tory of fungal infection, high grade graft-versus-host disease, T-cell suppressive therapy, long-lasting corticosteroid treatment and/or refractory underlying malignant disease (1, 2). An early diagnosis and prompt initiation of appropriate antifungal therapy are impera- tive and essential for a favourable clinical outcome. However, an early diagnosis is usually difficult to establish, due to the limited value of microscopy, mycological cultures, and conventional radiol- ogy. In general, the interval between subtle fungal tissue invasion and appearance of clinical signs and symptoms determines the time point of initiation of antifungal therapy and may have prognostic implications. Initiation of systemic antifungal therapy prior to estab- lishing the diagnosis of a fungal infection, may contribute to a better therapeutic outcome in high-risk patients. Around 30% of patients with FUO develop invasive fungal diseases during granulocytopenia. Radiology and in particular computed tomography plays an impor- tant role in the diagnosis of IFD, whereas the conventional chest X- ray may not helpful for early diagnosis of IFD in high-risk patients because of lack of sensitivity during granulocytopenia. The ’Multinational Association for Supportive Care in Cancer’ (MASCC) scoring system may be helpful to define the risk groups (low risk versus high risk) among patients with FUO and to perform a therapeutic stratification (3). Invasive aspergillosis (IA) is a serious complication in patients undergoing allogeneic haematopoietic stem cell transplantation (HSCT), particularly from donors other than HLA-identical sibling. Multivariate analyses showed that significant predictors of IA were delayed neutrophil engraftment, extensive chronic GVHD (cGVHD), secondary neutropenia and relapse after transplant. IA-related mortality among IA patients was 67% and was influenced by use of antithymocyte globulin, steroids, higher levels of creatinine, and lower levels of IgA and platelets. The outcome of IA depends on the severity of immunodeficiency and the status of the underlying disease (4). References (1) Mikolajewska A, Schwartz S, Ruhnke M. Antifungal treatment strategies in patients with haematological diseases or can- cer: from prophylaxis to empirical, pre-emptive and targeted therapy. Mycoses 2011. (2) Hoenigl M, Strenger V, Buzina W, Valentin T, Koidl C, W€olfler A et al. European Organization for the Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) host factors and invasive fungal infections in patients with haematological malignancies. J An- timicrob Chemother 2012 Aug;67(8):2029-33. (3) Klastersky J, Paesmans M, Rubenstein EB, Boyer M, Elting L, Feld R et al. The Multinational Association for Supportive Care in Cancer risk index: A multinational scoring system for identifying low-risk febrile neutropenic cancer patients. J Clin Oncol 2000; 18 (16):3038-3051. (4) Mikulska M, Raiola AM, Bruno B, Furfaro E, Van Lint MT, Breg- ante S et al. Risk factors for invasive aspergillosis and related mortal- ity in recipients of allogeneic SCT from alternative donors: an analysis of 306 patients. Bone Marrow Transplant 2009; 44(6):361-370.

Abstract Number: m14

Conference Year: 2013

Link to conference website: NULL

New link: NULL

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