A 28-year-old man was referred to our institution on May 2003, because of fever of unknown origin for the last 6 weeks. Acute myeloid leukemia was diagnosed in March 2003 and the patient received induction chemotherapy on March 28. Within days following chemotherapy, the patient developed high fever between 38°C and 40°C, which was persistent despite the use of broad-spectrum antibiotics (ceftazidime-amikacine-vancomycine) and voriconazole. On admission, physical examination was normal. Total white blood cell count was 9500/mm3. Three blood cultures, serum cryptococcal latex agglutination test, Aspergillus and Candida antigens were negative. An abdominal CT scan showed multiple abscesses in the liver and the spleen. The central venous catheter was removed but its culture was negative. A liver biopsy revealed histopathologic evidence of Candida spp infection but the culture remained negative. Treatment with intravenous amphotericin B (1 mg/kg/d) was started because of the concern for imidazole resistance. After 15 days, because of persistent fever, amphotericin B was switched to a liposomal formulation (Ambisome°) in combination with caspofungin for 6 weeks and to 5 fluocytosine for 3 weeks. After 8 weeks of antifungal therapy, the patient's condition deteriorated with the persistence of fever. Treatment with prednisone was then started at 1 mg/kg/d. The patient's condition improved dramatically and fever decreased within 2 days. Consolidation chemotherapy with amsacrine and aracytine was started 7 days later. Prednisone was continued for 3 weeks and then decreased progressively. Abdominal CT scan showed a significant decrease in the size and number of hepatosplenic lesions. Antifungal therapy was switched to oral voriconazole. Prednisone was stopped after 6 weeks and the patient remained afebrile and his condition improved. He underwent an allogenic bone marrow transplantation and is still considered in remission. Candida spp. is the most frequent cause of invasive infection in neutropenic patients. The main clinical manifestation ofCandida infection is candidemia, however chronic disseminated disease is not rare. Diagnosis is difficult because cultures remains often negative. Histologic examination is the most reliable diagnostic procedure. Treatment is very long (at least 4-6 months) and the persistence of fever and hepatosplenic lesions on CT scan could delay the treatment of the hematologic malignancy with a high risk of progression. In such situations, steroid treatment in combination with antifungal therapy could improve clinical manifestations and avoid any delay in the management of the malignancy.
Full conference title:
- RICAI 24th (2004)