Reactions 1213 - 2 Aug 2008

Author comment: Predisposing factors to disseminatedCandida infection in patients with leukaemia include younger SAntibacterials/antineoplastics age, prolonged neutropenia, prophylactic antibiotic use,severe mucositis and TPN. The predisposing factors forInvasive pulmonary aspergillosis and hepatosplenicinvasive aspergillosis in immunocompromised patientscandidiasis (one fatal): 2 case reportsinclude cytotoxic chemotherapy, prolonged neutropenia, andTwo boys, aged 15 and 16 years, developed combinedcorticosteroids or other immunosuppressive therapies.invasive pulmonary aspergillosis and hepatosplenicNeutropenic enterocolitis can be one of the predisposingcandidiasis during treatment with antineoplastics [drugs,factors for development of hepatosplenic candidiasis.dosages and duration of treatment to reaction onset not clearly

stated] and antibacterials. The 15-year-old boy subsequently Avci Z, et al. Double invasive fungal infection and typhlitis in children with acutedied due to pulmonary haemorrhage. lymphoblastic leukemia. Pediatric Hematology and Oncology 25: 99-106, No. 2,

2008 - Turkey 801118344The 15-year-old boy was diagnosed with acutelymphoblastic leukaemia (ALL) and started receiving inductionchemotherapy according to St Jude Total XIII protocol. Onday 15 of induction chemotherapy, he developed febrileneutropenia and oral mucositis. He had expiratory wheezingover both lung fields and a chest -x-ray showed hyperinflationin both lung fields. He received empirical antibacterialtreatment with imipenem and amikacin [dosages not stated]along with nebulised salbutamol [albuterol] andbeclometasone. Total parenteral nutrition (TPN) was started.On day 5 of antibacterial treatment, he developed abdominalpain and vomiting. He had tenderness in his right lowerabdominal quadrant, which suggested neutropenicenterocolitis. Metronidazole was added and oral nutrition wasstopped. On day 7, an abdominal CT scan showed thickeningof the ascending colon and caecum, consistent withenterocolitis. Nodular hypodense areas in the liver and spleenparenchyma were observed, suggestive of hepatospleniccandidiasis. He started receiving liposomal amphotericin Band vancomycin and, 1 day later, developed haemoptysis andpleuritic chest pain. Examination showed fine rales in his rightlung. A chest CT scan showed multiple nodular consolidationareas in the lung parenchyma, with some cavitations.Laboratory investigations showed the following: WBC count0.232 × 109/L, platelet count 17.5 × 109/L, no neutrophils in aperipheral blood smear, and INR 1.7. He received vitamin K,fresh-frozen plasma and thrombocyte suspensions. Blood andsputum cultures revealed amphotericin B-sensitive Candidatropicalis and Aspergillus fumigatus, respectively. On day 14after antibacterial initiation, his neutropenia,thrombocytopenia, coagulopathy and enterocolitis symptomsrecovered but, 6 days later, he died due to massive pulmonaryhaemorrhage. Postmortem analysis showed lesions consistentwith invasive candidiasis of the liver and invasive aspergillosisof the lungs.

The 16-year-old boy, who had a history of a dairy product-rich diet, was diagnosed with ALL, and started receivingchemotherapy according to ALL-BFM 95 protocol. Afterreceiving high-dose methotrexate and cytarabine duringconsolidation phase, he developed febrile neutropenia andoral mucositis. He then started receiving empiricalantibacterial therapy with cefepime and amikacin [dosages notstated]. On day 2 of antibacterial treatment, he developedabdominal pain and tenderness in his right lower abdominalquadrant. Abdominal ultrasonography and CT scan showedneutropenic enterocolitis. He started receiving metronidazoleand TPN. He had a WBC count of 0.02 × 109/L with noneutrophils observed in the peripheral blood smear. On day 6of antibacterial treatment, he started receiving empiricalliposomal amphotericin B and a granulocyte colony-stimulating factor; at this time, he had normal chest CT scanfindings. Febrile neutropenia showed improvement on day 11of antibacterial treatment, but he had increased serum alkalinephosphatase (1710 U/L) and galactomannan (8.1) levels. Bloodculture obtained before antifungal therapy initiation showedamphotericin B-sensitive Candida kefyr. Antibacterials werediscontinued on day 14. After 2 days, he had recurrent fever.Repeat chest CT scan findings were consistent with invasivepulmonary aspergillosis. Abdominal CT scan was indicative ofhepatosplenic candidiasis. His liposomal amphotericin B dosewas increased. Antifungal therapy was stopped on day 42. Heremained in complete remission and maintenance therapy wascontinued.

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