Purpose: A 24-year old male patient with myelodysplastic syndrome (refractory anemia with excess blasts I - RAEB-1) received bone marrow hematopoietic stem cells (2,12x108 cells/kg) from his HLA-identical sister. Methods: On day +26 he presented with fever, chills and abdominal pain. Fluconazole was discontinued and amphotericin B colloidal dispersion (ABCD) was started (neutrophil counts 200/mm3). He was admitted to the inpatient unit on day +29 to receive a boost of bone marrow stem cells (2,7 x 108 cells/kg) because of graft failure (leucocyte counts 100 cells/mm3 platelet counts 15.000/mm3) and was switched to lipossomal amphotericin B (3mg/kg/day) because of intolerance. Results: A CT scan was performed which showed areas of alveolar condensation associated with halo sign on thoracic scan that suggested possible pulmonary aspergillosis and thickened ceccal appendix on abdominal scan. On day +36, an erythematous violaceous nodule appeared on the patient’s right mandibular angle which progressed to a pustule and was biopsied The skin biopsy showed presence of septate hyphal structures compatible with Aspergillus and these same structures within the walls and lumen of blood vessels representing angioinvasion with scant inflammatory cells with few NK cells, CD4+, CD8+, CD20+ and absence of neutrophils. The most frequent inflammatory cells found were macrophage CD68+. The immunohistochemically stained showed predominance of Th2-phenotype cytokines IL-4 and IL-10 and impairment of Th1- phenotype response with no IFN-gamma, IL-8, TNF and IL-6. The culture was positive for Aspergillus sp, diagnosing proven cutaneous invasive aspergillosis.The next day he had a sudden episode of right hemiparesis and facial paralysis. Head CT scan was performed and showed large hypodense lesions on left frontal area and left subcortical temporal area. Although the possibility of fungal abscess (possible CNS aspergillosis) was considered, biopsy was contraindicated because the patient remained thrombocytopenic (14.000 platelets/mm3). As the patient had shown no improvement of symptoms with pulmonary, cutaneous and central nervous system lesions suggesting fungal infection, voriconazole (4mg/kg IV de 12/12 hours) was added to the regimen. Conclusions: He remained pancytopenic throughout the whole period and neurological symptoms worsened over the course of days. After 23 days of antifungal therapy the patient progressed to death on day +49, with 11 days of combination antifungal therapy.
Full conference title:
4th Advances Against Aspergillosis
- AAA 4th (2010)