aspergillus infection is associated with unacceptably high mortality and is the primary cause of infectious death following stem cell transplantation (SCT). Therefore until recently patients with history of invasive fungal infection were often not considered as candidates for allogeneic SCT. Here we report four children (7, 8, 17 and 18 years old) with proven or probable pulmonary aspergillosis (PA) diagnosed pre-transplant in three patients (4 months, 1 month, 1 week) and in one 6 months after allogeneic SCT. Transplantation from unrelated donor was indicated in three patients (first partial remission of MLL/AF6 positive AML, second complete remission of Ph+ ALL, AML/MDS with 5q-). One patient was transplanted using matched sibling as frontline therapy for severe aplastic anemia (SAA). Diagnosis of PA was based on clinical symptoms and typical CT scans in four, positive culture from bronchoalveolar lavage in two ( aspergillus species, aspergillus fumigatus). Abelcet was primary used to succesfully treat patient with proven PA diagnosed 4 months before SCT from matched unrelated donor while on chemotherapy. Over transplantation period voriconazole was used (40 days) and despite later manifestation of acute graft versus host disease (GVHD) grade II no reactivation of aspergillosis has occurred. In patient with SAA PA was diagnosed at the time he was treated for grade IV GVHD. Frontline therapy with voriconazole was initiated, for clinical progression combined with caspofungin for 50 days, than again treated with voriconazole only (total 6 months). Over next 6 months with no signs of further reactivation of PA immunosuppression was gradually discontinued and finally voriconazole was stopped. Two patients in long-lasting pre-transplant marrow aplasia were succesfully treated for probable PA (concomitant Candida crusei sepsis in one) for 28 days with caspofungin overlaping with voriconazole for one week and continue on voriconazole since throughout period of acute GVHD grade II in both. CT scans showed resolution of PA in all four patients with no reactivation 13, 4, 2 and 2 months following SCT despite all patients being treated for grade II-IV GVHD. To prove fungal infection is not easy. In immunocompromised patients therapy must often be initiated as soon as the diagnosis is suspected. Both caspofungin and voriconazole alone or in combination seem to be tolerable and efficious tools and are promising alternatives to amphotericin B lipid formulations.
Full conference title:
30th Annual Meeting of the European Group for Blood and Marrow Transplantation
- EBMT 2004