Voriconazole secondary prophylaxis in an HLA identical bone marrow transplant recipient with previous pulmonary aspergillosis.

Mordini, N., D. Mattei, A. Gallamini, A. Bacigalupo, C. Viscoli (Cuneo, Genoa, I)


Introduction: Invasive Aspergillosis (IA) during the remission/induction treatment of acute myeloid leukemia (AML) is expected to relapse if the patient undergo bone marrow transplantation. We report an AML patient who developed proven pulmonary aspergillosis (according the revised EORTC Mycoses Study Group criteria), failed secondary prophylaxis with liposomal amphotericin-b (Am-B), was treated with voriconazole (VOR) and successfully underwent BMT under VOR prophylaxis. Patients and methods : An 44 years old man was diagnosed on July 2000 with M4 AML. On day 05.07 he was given standard induction treatment with daunomycin, etoposide, cytosine arabynoside. The patient was monitored with twice weekly ELISA assay for galactomannan and weekly chest CT scan. The patient had 3 consecutive positive ELISA test on days 10.07, 13.07 and 17.07, without fever or respiratory symptoms. He started conventional Am-B on 15.07. The 1st CT scan was negative, but the 2nd ( 27.07) showed a pulmonary lesion, that later (03.08) became escavated. Needle biopsy culture yielded Aspergillus. Antigenemia fell to negativity following standard and then liposomal Am-B treatment. On day 12.08 reinduction treatment for resistant leukemia with high-dose ARA-C, DNM and VP16 was started, associated with liposomal Am-B secondary prophylaxis. The patient achieved hematological recovery and complete remission, but on day 04.09, despite negative antigenemia, fever and chest pain recurred and a CT scan showed a second pulmunary nodulation. Treatment with voriconazole (VOR) was started on day 15.09 and the patient underwent BMT. After conditioning regimen with TBI and cyclophosphamide, he was grafted with sibling HLA-identical BM on day 05.10. The patient reached ANC count > 500/mm3 on day +16 and Plts >30000/mm3 on day +22. During neutropenia there was only 1 FUO episode, and aspergillus antigenemia was always negative. There was only a mild liver toxicity, leading to VOR dosage reduction. CT scan performed on day 27.10 didn't show any pulmonary lesion. Conclusion: at least in this case VOR was very effective in preventing further relapse of pulmonary aspergillosis. Obviously, this result should to be confirmed in prospective studies.

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11th European Congress of Clinical Microbiology and Infectious Diseases
    • ECCMID 11th (2001)