Successful Treatment of Resistant Invasive Aspergillosis with Combination of Caspofungin Acetate and Voriconazole during Aggresive Treatment of AML including BMT. Session Type: Publication Only

Zdenek Racil, Jiri Mayer

Author address: 

Internal Medicine-Hematooncology, University Hospital Brno, Brno, Czech Republic

Abstract: 

Background: Invasive infection by Aspergilus sp. is an emerging fungal infection in immunocompromised patients associated with high mortality. Even new antifungal agents are available now (as voriconazole and caspofungin acetate), there is still high percentage of patients who do not respond, especially when neutropenia is present. Mechanism of action of these two agents allows their combination for possible better effect in patients who do not respond to initial treatment, especially during serious neutropenia. Case report: A 31-year-old man with acute myeloid leukemia (AML) was admitted to our inst. in 10/02. After induction chemotherapy (CHT) he didnt achieved remission of AML and severe neutropenia persisted. Reinduction CHT (11/02), that led to achievement of complete remission of AML, was complicated by febrile neutropenia with empiric administration of Amfo B and epididymitis on right side. After ending of Amfo B daily fevers continued and bilateral interstitial pneumonia developed (12/02). Since BAL wasnt possible to perform and regarding to results on HRCT empiric treatment with high dose TMP-SMX started. On 23/12/02 ultrasonic testing found hepatomegaly and splenomegaly with multiple focuses in spleen and splenectomy was proceeded (histology-infiltration by Aspergillus sp.). Because invasive aspergillosis had occurred during and immediately after Amfo B treatment, on 31/12/02 caspofungin acetate (70mg IV on day 1, followed with 50mg/day IV) was administered. Due to continuing fever and relapse of right testis enlargement on 16/01/03 caspofungin acetate was replaced by voriconazole (6mg/kg bid. IV on day 1, followed with 200mg bid. PO) and first consolidation CHT started. On 30/01/02 right orchiectomy was performed (histology-infiltration by Aspergillus sp. in regression). Dose of voriconazole was enhanced to 300mg bid. PO. Fevers slightly decreased but on CT scan multiple focuses in liver and both kidneys were found. Due to insufficient effect of separate application of two antifungals and necessity of second consolidation CHT on 12/02/03 combined antifungal treatment with voriconazole 300mg bid. PO and caspofungin acetate 50mg/day IV was initiated. After period of neutropenia fevers decreased to subfebrile levels. CT scan on 31/03/03 showed regression of aspergillus focuses. On 05/04/03 conditioning for non-myeloablative BMT from match unrelated donor began. All peritransplant period was without infection complications and from 15/04/03 patient was afebrile. CT scan on day +22 (day 84 of combined antifungal treatment) and also CT scan on day +51 (day 113 of combined antifungal treatment) showed further regression of focuses in liver and kidneys. Due to this favourable findings and because of patient was without signs of acute GVHD on day +51 after BMT (day 113 of combined antifungal treatment) treatment with caspofungin acetate was finished and voriconazole 300mg bid. PO (200mg bid PO from day +91) continued. On CT scan performed on day +84 there were not any remeins of fungal focuses. Patients was in complet remission of AML, without any signs of GVHD. On day +98 imunosupression and on day +131 after BMT antifungal treatment was ended. Conclusion: With combination of voriconazole and caspofungin acetate we were able to salvage a young patient with resistant invasive aspergillosis, that did not respond to conventional antifungal treatment with separate aplication of antifungals. Also we were able to continue with aggresive treatment of AML including non-myeloablative BMT from match unrelated donor during active fungal infection. Abstract #5499 appears in Blood, Volume 102, issue 11, November 16, 2003
2003

abstract No: 

5499

Full conference title: 

American Society of Hematology 45th Annual Meeting
    • ASH 45th (2003)