Antineoplastics/corticosteroids
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Reactions 1243 - 14 Mar 2009 WHO ADR database contained one report of aspergillosis (MedDRA) associated with carmustine. ★ S Antineoplastics/corticosteroids Aspergillus terreus infection (first report with carmustine): case report A 60-year-old woman developed pulmonary and cerebral Aspergillus terreus infection after carmustine polifeprosan 20 wafer implantation (Gliadel) and treatment with temozolomide and chronic corticosteroids [dosages and durations of therapies to reaction onset not stated]. The woman underwent gross total resection with carmustine polifeprosan 20 wafer implantation, external beam radiotherapy and two cycles of temozolomide chemotherapy, for left temporal lobe glioblastoma. Her clinical course was complicated by deep vein thrombosis with pulmonary embolisms, allergic reactions to phenytoin and valproic acid, heparin-induced thrombocytopenia and long-term corticosteroid requirement [specific drugs and indication not clearly stated] with subsequent cushingoid features. Grade-3 leucopenia and neutropenia were also noted following the first cycle of temozolomide. Tumour progression was noted 5 months after initial diagnosis, prompting an additional temozolomide cycle. During a routine follow-up, the patient’s family reported a 2–3 week history of functional decline. She was nonambulatory, confused, excessively sleepy during the day and had nocturnal visual and auditory hallucinations. Her neurological examination was limited, she demonstrated lack of antigravity strength in the proximal lower extremities and responded to questions and followed commands inconsistently. She had a BP of 154/101 and an area of cellulitis associated with a firm, tender, nodular area in the right axilla. Her serum glucose was 453 mg/dL and she had mildly elevated lactate dehydrogenase and total bilirubin. Hypoventilation and a questionable retrocardiac nodular opacity were evident during chest radiograph. CT scan reveled multifocal parenchymal opacities, some consolidated and some nodular in appearance. Urine culture was positive for Candida albicans. CSF had a WBC count of 7 [no units stated] with 99% neutrophils, a RBC count of 1 [no units stated], a glucose level of 99 mg/dL and a protein level of 65 mg/dL. Two new hypodense lesions were observed upon head CT. Brain MRI characterised these lesions as faintly enhancing with focal haemorrhage. Subsequent excisional brain biopsy, revealed extensive necrosis with the more intact fragments showing intense neutrophilic response, vascular thrombosis and necrosis. In the abscess, extensive tissue haemorrhage was observed. Septal fungi forming 45° angle branching were observed. Cultures from the brain lesion and subsequent bronchoalveolar lavage grew Aspergillus terreus. Bronchial lavage cultures also grew Candida albicans. The woman received amphotericin B lipid complex and fluconazole; however clinical decline persisted and symptomatic brain oedema increased. Hospice care was pursued and she died 6 days after the diagnosis was established; no postmortem examination was performed. Author comment: "In our patient, chronic steroid use in the setting of concurrent chemotherapy appeared to have been the major risk factor. . . Our patient did have a persistently low absolute lymphocyte count for most of her treatment course, attributed to both the provision of high- dose steroids and the specific chemotherapy agent, temozolomide". Damek DM, et al. Aspergillus terreus brain abscess mimicking tumor progression in a patient with treated glioblastoma multiforme. Clinical Neuropathology 27: 400-407, No. 6, Nov-Dec 2008 - USA 801132182 » Editorial comment: A search of AdisBase, Medline and Embase did not reveal any previous case reports of Aspergillus terreus infection associated with carmustine. The 1 Reactions 14 Mar 2009 No. 1243 0114-9954/10/1243-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved
Transcript of Antineoplastics/corticosteroids
Reactions 1243 - 14 Mar 2009
WHO ADR database contained one report of aspergillosis(MedDRA) associated with carmustine.★ SAntineoplastics/corticosteroids
Aspergillus terreus infection (first report withcarmustine): case report
A 60-year-old woman developed pulmonary and cerebralAspergillus terreus infection after carmustine polifeprosan20 wafer implantation (Gliadel) and treatment withtemozolomide and chronic corticosteroids [dosages anddurations of therapies to reaction onset not stated].
The woman underwent gross total resection withcarmustine polifeprosan 20 wafer implantation, externalbeam radiotherapy and two cycles of temozolomidechemotherapy, for left temporal lobe glioblastoma. Herclinical course was complicated by deep vein thrombosiswith pulmonary embolisms, allergic reactions to phenytoinand valproic acid, heparin-induced thrombocytopenia andlong-term corticosteroid requirement [specific drugs andindication not clearly stated] with subsequent cushingoidfeatures. Grade-3 leucopenia and neutropenia were alsonoted following the first cycle of temozolomide. Tumourprogression was noted 5 months after initial diagnosis,prompting an additional temozolomide cycle. During aroutine follow-up, the patient’s family reported a 2–3 weekhistory of functional decline. She was nonambulatory,confused, excessively sleepy during the day and hadnocturnal visual and auditory hallucinations. Herneurological examination was limited, she demonstratedlack of antigravity strength in the proximal lowerextremities and responded to questions and followedcommands inconsistently. She had a BP of 154/101 and anarea of cellulitis associated with a firm, tender, nodular areain the right axilla. Her serum glucose was 453 mg/dL andshe had mildly elevated lactate dehydrogenase and totalbilirubin. Hypoventilation and a questionable retrocardiacnodular opacity were evident during chest radiograph. CTscan reveled multifocal parenchymal opacities, someconsolidated and some nodular in appearance. Urineculture was positive for Candida albicans. CSF had a WBCcount of 7 [no units stated] with 99% neutrophils, a RBCcount of 1 [no units stated], a glucose level of 99 mg/dL anda protein level of 65 mg/dL. Two new hypodense lesionswere observed upon head CT. Brain MRI characterisedthese lesions as faintly enhancing with focal haemorrhage.Subsequent excisional brain biopsy, revealed extensivenecrosis with the more intact fragments showing intenseneutrophilic response, vascular thrombosis and necrosis.In the abscess, extensive tissue haemorrhage wasobserved. Septal fungi forming 45° angle branching wereobserved. Cultures from the brain lesion and subsequentbronchoalveolar lavage grew Aspergillus terreus. Bronchiallavage cultures also grew Candida albicans.
The woman received amphotericin B lipid complex andfluconazole; however clinical decline persisted andsymptomatic brain oedema increased. Hospice care waspursued and she died 6 days after the diagnosis wasestablished; no postmortem examination was performed.
Author comment: "In our patient, chronic steroid use inthe setting of concurrent chemotherapy appeared to havebeen the major risk factor. . . Our patient did have apersistently low absolute lymphocyte count for most of hertreatment course, attributed to both the provision of high-dose steroids and the specific chemotherapy agent,temozolomide".Damek DM, et al. Aspergillus terreus brain abscess mimicking tumor progressionin a patient with treated glioblastoma multiforme. Clinical Neuropathology 27:400-407, No. 6, Nov-Dec 2008 - USA 801132182
» Editorial comment: A search of AdisBase, Medline andEmbase did not reveal any previous case reports ofAspergillus terreus infection associated with carmustine. The
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Reactions 14 Mar 2009 No. 12430114-9954/10/1243-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved
