Management of IFI in Febrile Neutropenic Patients: A Case ... · PDF fileWith presumptive...
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16 UHOD Number: 3 [Suppl 2] Volume: 23 Year: 2013 TO THE EDITOR: A 70 years old female patient who was previously diagnosed with relapsed chronic lymphocytic le- ukemia was referred to our clinic with complaints of fever, dyspnea and cough. The blood count and peripheral blood smear revealed neutropenia and she was hospitalized with the diagnosis of febrile neutropenia. Patient was already on the second month of alemtuzumab therapy which was known to cause serious immunosupression. Physical exa- mination revealed bilateral inspiratory crackles. With presumptive diagnosis of febrile neutropenia and bacterial pneumonia empirical extended spect- rum antibiotic combination with antipseudomonal activity was started (piperacillin-tazobactam and ciprofloxacin). She was still febrile on the 3rd day of antibiotics and aspergillus galactomannan was 0,70 (positive). Considering that piperacilin-tazo- bactam may cause false positive galctomannan re- sults 1 , in order to eliminate a possible pulmonary aspergillosis, HRCT was performed. HRCT sho- wed some scarce milimetric nodular consolidations with irregular margins and were surrounded by a halo with ground glass opacification (Figure 1A-B- C). Liposomal amphotericin B treatment was initi- ated depending on the positive galactomannan and halo signs on HRCT which were thought to be re- lated to an invasive aspergillus infection in an im- munocompromized patient. 2 In the meanwhile, bronchoscopic evaluation was requested to clarify and isolate the possible microorganism. Bronchos- copy was applied with no major complication and bronchoalveolar galactomannan was found to be 2.40 (positive). The fungal culture of bronchoalve- olar lavage revealed both aspergillus fumigatus (200 cfu/ml) and aspergillus flavus (1000 cfu/ml) which were known to be sensitive to liposomal amphotericin B therapy. 3 At the fourth day of lipo- somal amphotericin B treatment with appropriate dosage and administration, the fever subsided and the symptoms related to pneumonia regressed. Af- ter the third week of antifungal therapy, complete radiological response was achieved and liposomal amphotericin B was stopped at 4th week. In this immunocompromised patient, pulmonary aspergil- losis, which occured after highly immunosupres- sive therapy with alemtuzumab, was successfully treated with appropriate antifungal therapy and did not relapse. Management of IFI in Febrile Neutropenic Patients: A Case of Invasive Aspergillosis Treated with Liposomal Amphotericin B Omur G. SEVINDIK, Serife M. SOLMAZ, Celal ACAR, Inci ALACACIOGLU, Ozden PISKIN, Güner H. OZSAN, Bulent UNDAR, Fatih DEMIRKAN, M. Ali OZCAN Department of Hematology, Dokuz Eylul University Faculty of Medicine, Izmir, TURKEY ULUSLARARASı HEMATOLOJI-ONKOLOJI DERGISI LETTER TO EDITOR International Journal of Hematology and Oncology doi: 10.4999/uhod.13069
Transcript of Management of IFI in Febrile Neutropenic Patients: A Case ... · PDF fileWith presumptive...
16 UHOD Number: 3 [Suppl 2] Volume: 23 Year: 2013
TO THE EDITOR:
A 70 years old female patient who was previouslydiagnosed with relapsed chronic lymphocytic le-ukemia was referred to our clinic with complaintsof fever, dyspnea and cough. The blood count andperipheral blood smear revealed neutropenia andshe was hospitalized with the diagnosis of febrileneutropenia. Patient was already on the secondmonth of alemtuzumab therapy which was knownto cause serious immunosupression. Physical exa-mination revealed bilateral inspiratory crackles.With presumptive diagnosis of febrile neutropeniaand bacterial pneumonia empirical extended spect-rum antibiotic combination with antipseudomonalactivity was started (piperacillin-tazobactam andciprofloxacin). She was still febrile on the 3rd dayof antibiotics and aspergillus galactomannan was0,70 (positive). Considering that piperacilin-tazo-bactam may cause false positive galctomannan re-sults1, in order to eliminate a possible pulmonaryaspergillosis, HRCT was performed. HRCT sho-wed some scarce milimetric nodular consolidationswith irregular margins and were surrounded by ahalo with ground glass opacification (Figure 1A-B-C). Liposomal amphotericin B treatment was initi-
ated depending on the positive galactomannan andhalo signs on HRCT which were thought to be re-lated to an invasive aspergillus infection in an im-munocompromized patient.2 In the meanwhile,bronchoscopic evaluation was requested to clarifyand isolate the possible microorganism. Bronchos-copy was applied with no major complication andbronchoalveolar galactomannan was found to be2.40 (positive). The fungal culture of bronchoalve-olar lavage revealed both aspergillus fumigatus(200 cfu/ml) and aspergillus flavus (1000 cfu/ml)which were known to be sensitive to liposomalamphotericin B therapy.3 At the fourth day of lipo-somal amphotericin B treatment with appropriatedosage and administration, the fever subsided andthe symptoms related to pneumonia regressed. Af-ter the third week of antifungal therapy, completeradiological response was achieved and liposomalamphotericin B was stopped at 4th week. In thisimmunocompromised patient, pulmonary aspergil-losis, which occured after highly immunosupres-sive therapy with alemtuzumab, was successfullytreated with appropriate antifungal therapy and didnot relapse.
Management of IFI in Febrile Neutropenic Patients: A Case of Invasive Aspergillosis Treated
with Liposomal Amphotericin BOmur G. SEVINDIK, Serife M. SOLMAZ, Celal ACAR, Inci ALACACIOGLU, Ozden PISKIN,
Güner H. OZSAN, Bulent UNDAR, Fatih DEMIRKAN, M. Ali OZCAN
Department of Hematology, Dokuz Eylul University Faculty of Medicine, Izmir, TURKEY
ULUSLARARASı HEMATOLOJI-ONKOLOJI DERGISI LETTER TO EDITOR International Journal of Hematology and Oncology
doi: 10.4999/uhod.13069
REFERENCES
1. Boonsarngsuk V, Niyompattama A, Teosirimongkol C,
Sriwanichrak K. False-positive serum and bron-
choalveolar lavage Aspergillus galactomannan assays
caused by different antibiotics. Scand J Infect Dis 42:
461-468, 2010.
2. Cornely OA, Maertens J, Bresnik M, et al. Liposomal
amphotericin B as initial therapy for invasive mold
infection: a randomized trial comparing a high-loading
dose regimen with standard dosing (AmBiLoad trial).
Clin Infect Dis 44: 1289-1297, 2007.
3. Lass-Flörl C, Mayr A, Perkhofer S, et al. Activities of
antifungal agents against yeasts and filamentous fungi:
assessment according to the methodology of the
European Committee on Antimicrobial Susceptibility
Testing. Antimicrob. Agents Chemother 52: 3637-
3641, 2008.
Correspondence
Dr. Mehmet Ali ÖZCAN
Dokuz Eylül Üniversitesi T›p Fakültesi Hastanesi
Hematoloji Anabilim Dal›
Mithatpafla Cd
35340, ‹nciralt›, ‹ZM‹R / TURKEY
Tel: (+90.532) 335 37 21
Fax: (+90.232) 259 97 23
m-mail: [email protected]
17UHOD Number: 3 [Suppl 2] Volume: 23 Year: 2013
Figure 1A. Nodular consolidations with pleural effusion. Figure 1B. Scarce milimetric nodular consolidations withirregular margins.
Figure 1C. Nodular consolidations, one with regular marginsand the other with irregular margins and a halo with groundglass opacification.
