Contributions
Abstract: PB2061
Type: Publication Only
Background
Invasive fungal infections (IFI) needs a prompt identification of the fungus and aggressive anti-fungal treatment along with reversal of neutropenia and immunosuppression.
Aims
We describe a case of Mucormycosis where aggresive antifungal therapy & granulocyte infusions led to a successful outcome.
Methods
13 year old child with Acute Lymphoblastic Leukemia (NCI-HR with CNS-2 status at presentation) was on UK-ALL 2003 high risk protocol. He presented in week 4 of induction with multiple tender skin lesions over the body. Lesions were ovoid with black discoloration and ulceration of the central region with a surrounding rim of erythema. On enquiry, parents reported the presence of a damp wall in their residence which was probably the source of his infection. He was initially afebrile with CBC - Hb 7.5 g%, TLC 310/mm3 (0% neutrophils), platelet count 62000/mm3. He was empirically started on parenteral antibiotics along with anti-fungal therap with liposomal amphotericin-B and Voriconazole. Bedside skin biopsy from the lesion was performed and sent for bacterial, fungal culture and histopathology. KOH mount on the biopsy was suggestive of budding yeast with hyphae. In view of progressive increase of the size of the lesions, deterioration of clinical condition with high grade fevers , inj.Caspofungin was also added. Dexamethasone was rapidly tapered and stopped. He was also given growth factors(inj. G-CSF at 10 mcg/kg/day subcutaneously q24 hourly) and granulocyte infusions(1x1010/recipient body weight (kg)) until absolute neutrophil count (ANC) increased to more than 1000/mm3 for 2 consecutive days. CT chest was suggestive of 8 mm nodule in the right side of the lung. With supportive care and above medications, his clinical condition and CBC started improving by day 6 of hospital stay. On day 7 of hospitalisation, he started having restlessness, anxiety, disorientation to time and person along with hallucinations and urinary and bowel incontinence followed by intermittent episodes of aphasia and aggressive behaviour. MRI brain was normal. In view of a normal MRI and worsening of CNS symptoms, voriconazole induced adverse reaction was suspected and it was withdrawn and Posaconazole was started. His GCS gradually started improving and he also regained bowel and bladder continence.
The skin biopsy was reported as Mucor. His hallucinations and restlessness reappeared and hence posaconazole was stopped and amphotericin-B and caspofungin were continued. However, few days later he developed generalised erythematous, macular- papular, pruritic skin rash on his trunk region. Amphoericin-B induced hypersensitivity was suspected and hence it was also discontinued. He was then re-challenged with posaconazole and this time,he tolerated it well.
Results
Currently,the skin lesions have healed completely and in view of the final characterisation of the isolated fungus being reported as Mucormycosis, caspofungin has been withdrawn and he is on single agent posaconazole. Currently, the patient is well and skin lesions have healed completely.
Conclusion
There is extreme morbidity caused by IFI in neutropenic children. Combination anti-fungals, reducing immunosuppression and rapidly increasing the neutrophil count is essential, for the treatment of severe IFI. Avoidance of exposure to damp walls, seepage and construction areas must be emphasised to the care givers of neutropenic and immunosuppressed children.
Session topic: 31. Infectious diseases, supportive care
Keyword(s): Acute lymphoblastic leukemia, Fungal infection
Abstract: PB2061
Type: Publication Only
Background
Invasive fungal infections (IFI) needs a prompt identification of the fungus and aggressive anti-fungal treatment along with reversal of neutropenia and immunosuppression.
Aims
We describe a case of Mucormycosis where aggresive antifungal therapy & granulocyte infusions led to a successful outcome.
Methods
13 year old child with Acute Lymphoblastic Leukemia (NCI-HR with CNS-2 status at presentation) was on UK-ALL 2003 high risk protocol. He presented in week 4 of induction with multiple tender skin lesions over the body. Lesions were ovoid with black discoloration and ulceration of the central region with a surrounding rim of erythema. On enquiry, parents reported the presence of a damp wall in their residence which was probably the source of his infection. He was initially afebrile with CBC - Hb 7.5 g%, TLC 310/mm3 (0% neutrophils), platelet count 62000/mm3. He was empirically started on parenteral antibiotics along with anti-fungal therap with liposomal amphotericin-B and Voriconazole. Bedside skin biopsy from the lesion was performed and sent for bacterial, fungal culture and histopathology. KOH mount on the biopsy was suggestive of budding yeast with hyphae. In view of progressive increase of the size of the lesions, deterioration of clinical condition with high grade fevers , inj.Caspofungin was also added. Dexamethasone was rapidly tapered and stopped. He was also given growth factors(inj. G-CSF at 10 mcg/kg/day subcutaneously q24 hourly) and granulocyte infusions(1x1010/recipient body weight (kg)) until absolute neutrophil count (ANC) increased to more than 1000/mm3 for 2 consecutive days. CT chest was suggestive of 8 mm nodule in the right side of the lung. With supportive care and above medications, his clinical condition and CBC started improving by day 6 of hospital stay. On day 7 of hospitalisation, he started having restlessness, anxiety, disorientation to time and person along with hallucinations and urinary and bowel incontinence followed by intermittent episodes of aphasia and aggressive behaviour. MRI brain was normal. In view of a normal MRI and worsening of CNS symptoms, voriconazole induced adverse reaction was suspected and it was withdrawn and Posaconazole was started. His GCS gradually started improving and he also regained bowel and bladder continence.
The skin biopsy was reported as Mucor. His hallucinations and restlessness reappeared and hence posaconazole was stopped and amphotericin-B and caspofungin were continued. However, few days later he developed generalised erythematous, macular- papular, pruritic skin rash on his trunk region. Amphoericin-B induced hypersensitivity was suspected and hence it was also discontinued. He was then re-challenged with posaconazole and this time,he tolerated it well.
Results
Currently,the skin lesions have healed completely and in view of the final characterisation of the isolated fungus being reported as Mucormycosis, caspofungin has been withdrawn and he is on single agent posaconazole. Currently, the patient is well and skin lesions have healed completely.
Conclusion
There is extreme morbidity caused by IFI in neutropenic children. Combination anti-fungals, reducing immunosuppression and rapidly increasing the neutrophil count is essential, for the treatment of severe IFI. Avoidance of exposure to damp walls, seepage and construction areas must be emphasised to the care givers of neutropenic and immunosuppressed children.
Session topic: 31. Infectious diseases, supportive care
Keyword(s): Acute lymphoblastic leukemia, Fungal infection