engleski

Mini epidemics of systemic Trichosporon mucoides infection in neutropenic patients with leukemia

Background: Disseminated infection caused by Trichosporon spp. is one of the emerging mycoses in neutropenic patients. Several case reports so far describe individual cases of systemic Trichosporon spp. infections. Generally this infection carries a poor prognosis. Here we reported five consecutive cases of systemic Trichosporon mucoides infection in a short period of time in neutropenic patients. At our knowledge this is the first report of epidemic appearance of systemic Trichosporon infections. Patients: During the 4 month period Trichosporon mucoides were isolated from blood cultures in 5 patients at the same ward. There were 3 males and 2 females, 42-57 years old. Four patients were diagnosed with AML, and one had CML in transformation. All patients received induction chemotherapy and were severely neutropenic with ANC <0.1 x 109/l. All but one patient received antifungal prophylaxis with 300 mg fluconazole orally. Patients presented with general symptoms of severe infection that was not responding to standard antibiotic therapy three of them with severe leg pain. Four patients had characteristic papulous skin lesions with central necrosis. Biopsy of lesions yielded granulomatous inflammation with marked central necrosis and microbiology was positive for T. mucoides in all patients. Four out of five patients had pulmonary infiltrates, and two of them had pleural effusions. Three patients had liver focal lesions, the largest measuring up to 1.8 cm, accompanied with elevated liver enzymes ; two of them had also spleen infiltrates. Liver biopsy, done in one patient showed only inflammatory mononuclear infiltration, microbiology remained negative. In all patients initial therapy consisted of Amphotericin B, one patient responded favorably. In other four patients signs of infections or blood cultures remained positive despite Ampho B or Caspofungin therapy in one patient. According to data on in vitro susceptibility of T. mucoides voriconazole (6mg/kg loading dose, 4mg/kg continuing) was introduced. Four to 12 days later patients became afebrile with the regression of pulmonary infiltrates and pleural effusion. The recovery of neutrophil count correlate with regression if infection. Patients continue to receive voriconazole orally until discharge. All patients survived. They all received further intensive chemotherapy, one of them allergenic stem cell transplant without developing Trichosporon infection with the secondary prophylactic use of voriconazole therapy. Although the source of the epidemic at the hematology ward remained obscure, it seems that water or sewage system could be responsible because Trichosporon mucoides were revealed in almost all washstands in reverse isolation rooms were patients were maintained. The department was closed and cleaned after that no cases of systemic Trichosporon infections appeared. Conclusion: This report indicates possibility of epidemic appearance of systemic Trichosporon spp. infections and illustrates that voriconazole is efficient in the treatment of disseminated Trichosporon mucoides infections in neutropenic patients as well as in secondary prophylaxis in these patients.

Systemic fungal infection; Trichosporon mucoides; Leukemia

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