Antineoplastics
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Reactions 1303 - 29 May 2010 S Antineoplastics Fatal disseminated mucormycosis: case report A 63-year-old woman developed disseminated mucormycosis and died during treatment with cyclophosphamide, doxorubicin, prednisolone and rituximab (R-CHOP) for a leukaemic form of mantle cell non-Hodgkin lymphoma [dosages not stated]. The woman, who had received her first R-CHOP chemotherapy 7 days ago, was hospitalised with vomiting, nausea, loss of appetite, fever and abdominal pain, which had started 2 days earlier. Physical examination showed right upper quadrant tenderness and petechiae on her back. As she had a history of cholelithiasis, she was internalised with suspected acute cholecystitis. Laboratory tests revealed the following: WBC count 9.1 × 10 9 /L (2% monocytes, 45% lymphocytes and 53% polymorphonuclear leucocytes), platelet count 28 × 10 9 /L, haemoglobin 11.2 g/dL, ALP 301 U/L, LDH 505 IU/L, GGT 45 U/L, AST 76 IU/L and ALT 35 U/L. During follow-up, she had a temperature of 38.1°C, which did not resolve in 1 hour. On hospital day 3 (day 10 of chemotherapy), she developed neutropenia and recurrent fever. The woman received ciprofloxacin, cefepime and a granulocyte colony-stimulating factor. On the second day of antibacterial therapy, she developed an ecymotic lesion on her right malleolus; her fever persisted. On day 3 of antibacterial treatment, her lesion became larger, her right ankle developed oedema and she developed a bullous lesion on her right malleolus. She also developed other ecymotic lesions on her left plantar surface and presacral region. Direct imaging of her right ankle revealed only soft tissue swelling. Her platelet count increased. Analysis of joint aspiration fluid showed a WBC count of 4 × 10 9 /L and 71% neutrophils. Microscopy did not detect any micro- organisms and cultures were negative. Ecthyma gangrenosum and pseudomonas infection were suspected so cefepime was replaced by imipenem. She reported persistent abdominal pain. Abdominal CT demonstrated cholelithiasis, multiple intra-abdominal lenfadenomegalies and multiple infarctions at the kidneys and spleen. On day 4 of antibacterial treatment, her fever resolved and her neutrophil count increased. She reported feeling well except for ankle pain. However, 2 days later, her condition deteriorated. She had a high creatinine level and a renal ultrasound showed no blood flow at the renal arteries and veins. She received haemodialysis, but her condition deteriorated further and she died on hospital day 10. Autopsy revealed ischaemic infarction of her diaphragm, kidneys, heart, spleen, lung, SC tissues and gut muscosa caused by invasion by fungal hyphae, which were morphologically compatible with mucormycosis. Author comment: "The main risk factor for this infection is probably the prolonged and profound neutropenia secondary to the myeloablative treatments used for the underlying hematologic malignancy. . . She had a leukemic form of mantle cell lymphoma that caused serious immunosuppression itself, received corticosteroid therapy as a component of chemotherapy regimen." Alacacioglu I, et al. Fatal disseminated mucormycosis in a patient with mantle cell non-hodgkin’s lymphoma: An autopsy case. Brazilian Journal of Infectious Diseases 13: 238-241, No. 3, Jun 2009. Available from: URL: http:// dx.doi.org/10.1590/s1413-86702009000300017 - Turkey 803016417 1 Reactions 29 May 2010 No. 1303 0114-9954/10/1303-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved
Transcript of Antineoplastics
Reactions 1303 - 29 May 2010
SAntineoplastics
Fatal disseminated mucormycosis: case reportA 63-year-old woman developed disseminated
mucormycosis and died during treatment withcyclophosphamide, doxorubicin, prednisolone andrituximab (R-CHOP) for a leukaemic form of mantle cellnon-Hodgkin lymphoma [dosages not stated].
The woman, who had received her first R-CHOPchemotherapy 7 days ago, was hospitalised with vomiting,nausea, loss of appetite, fever and abdominal pain, whichhad started 2 days earlier. Physical examination showedright upper quadrant tenderness and petechiae on herback. As she had a history of cholelithiasis, she wasinternalised with suspected acute cholecystitis. Laboratorytests revealed the following: WBC count 9.1 × 109 /L (2%monocytes, 45% lymphocytes and 53%polymorphonuclear leucocytes), platelet count 28 × 109 /L,haemoglobin 11.2 g/dL, ALP 301 U/L, LDH 505 IU/L, GGT45 U/L, AST 76 IU/L and ALT 35 U/L. During follow-up, shehad a temperature of 38.1°C, which did not resolve in1 hour. On hospital day 3 (day 10 of chemotherapy), shedeveloped neutropenia and recurrent fever.
The woman received ciprofloxacin, cefepime and agranulocyte colony-stimulating factor. On the second dayof antibacterial therapy, she developed an ecymotic lesionon her right malleolus; her fever persisted. On day 3 ofantibacterial treatment, her lesion became larger, her rightankle developed oedema and she developed a bullouslesion on her right malleolus. She also developed otherecymotic lesions on her left plantar surface and presacralregion. Direct imaging of her right ankle revealed only softtissue swelling. Her platelet count increased. Analysis ofjoint aspiration fluid showed a WBC count of 4 × 109 /L and71% neutrophils. Microscopy did not detect any micro-organisms and cultures were negative. Ecthymagangrenosum and pseudomonas infection were suspectedso cefepime was replaced by imipenem. She reportedpersistent abdominal pain. Abdominal CT demonstratedcholelithiasis, multiple intra-abdominal lenfadenomegaliesand multiple infarctions at the kidneys and spleen. Onday 4 of antibacterial treatment, her fever resolved and herneutrophil count increased. She reported feeling wellexcept for ankle pain. However, 2 days later, her conditiondeteriorated. She had a high creatinine level and a renalultrasound showed no blood flow at the renal arteries andveins. She received haemodialysis, but her conditiondeteriorated further and she died on hospital day 10.Autopsy revealed ischaemic infarction of her diaphragm,kidneys, heart, spleen, lung, SC tissues and gut muscosacaused by invasion by fungal hyphae, which weremorphologically compatible with mucormycosis.
Author comment: "The main risk factor for this infectionis probably the prolonged and profound neutropeniasecondary to the myeloablative treatments used for theunderlying hematologic malignancy. . . She had a leukemicform of mantle cell lymphoma that caused seriousimmunosuppression itself, received corticosteroid therapy asa component of chemotherapy regimen."Alacacioglu I, et al. Fatal disseminated mucormycosis in a patient with mantle cellnon-hodgkin’s lymphoma: An autopsy case. Brazilian Journal of InfectiousDiseases 13: 238-241, No. 3, Jun 2009. Available from: URL: http://dx.doi.org/10.1590/s1413-86702009000300017 - Turkey 803016417
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Reactions 29 May 2010 No. 13030114-9954/10/1303-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved
