In neutropenic pts, IPA remains a life-threatening complication. Nevertheless, an early diagnosis (correlated with a better prognosis) could be achieved by using thoracic CT scan (halo or air-crescent signs). We analyzed the features of IPA occurred in 59 pts with hematological malignancies (acute leukemia=51) since 1988. All but one pts were neutropenic (median duration before IPA=19d). Thirty-one pts had a definite IPA (positive tissue biopsy and CT halo or air-crescent signs). Eighteen pts had an highly probable IPA (positive culture of BAL and positive CT scan) while 10 pts had a probable IPA (positive CT scan and positive Aspergillus antigen test on BAL and or serum). At time of IPA diagnosis (systematically based on first CT halo sign since 1991), antifungal treatment was started (Itraconazole=16, AmB=4, combination of both= 28, Voriconazole=6 and ABLC=5). A surgical resection of aspergillary lesion was combined with medical therapy in 23 cases. Forty-three pts (73%) were cured or improved (median survival=425d) while 16 pts died from IPA (median survival=28d). Univariate analysis (Log-rank test) showed that: the achievement of hematological complete response (p=0.0001), the time (shortened with early CT scan use) to IPA diagnosis (p=0.007), a pulmonary unilateral involvement (p=0.03), the occurrence of an air-crescent sign after IPA diagnosis (p=0.0001), a fibrinogen level less than 9g/l in the 10 days after IPA diagnosis (p=0.0001) and a surgical resection of aspergillary lesion (p=0.04) were associated with an improved outcome. In a multivariate analysis (Cox model), a bilateral pulmonary involvement (p=0.05), the lack of air-crescent sign occurrence (p=0.005) and a fibrinogen level above 9g/l (p=0.001) remained the 3 independent factors associated with a worse survival. At 100 days after IPA diagnosis, 95% of pts with none or 1 of these independent factors were alive vs 45% and 0% of pts with 2 or 3 factors respectively (p=0.0001). In conclusion, this study confirms the necessity to obtain an early IPA diagnosis (that could be achieved with systematic use of early CT scan) for outcome improvement. After IPA diagnosis, the monitoring of plasmatic fibrinogen level and the detection of air crescent sign could be helpful for the management of IPA in neutropenic pts. The hematological outcome remains a major factor for long term survival.
Full conference title:
38th Interscience Conference on Antimicrobial Agents and Chemotherapy
- ICAAC 38th