Widespread subcutaneous nodules as a manifestation of breakthrough invasive aspergillosis in a bone marrow transplant patient: assessment of disease extension by positron emission tomography scan imaging

Abstract number: P1774

Abecasis M., Lapa P., Teixeira G., Miranda N., Nascimento Costa J., Saraiva Z.

Invasive aspergillosis often presents as a respiratory tract infection in transplant patients, but after haematogenous disssemination virtually any other organ may be involved. Metastatic cutaneous aspergillosis usually presents as necrotising cutaneous papules or ulcerating skin lesions due to embolisation and skin infarcts. We report an unusual form of disseminated aspergillosis and the usefulness of positron emission tomography (PET) scan imaging in assessing its extension.

An acute leukaemia patient underwent an unrelated mismatched non-myeloablative allogeneic stem cell transplantation after highly immunosuppressive conditioning. Primary antifungal prophylaxis was with itraconazol oral solution. An episode of acute gut graft vs host disease was treated with high dose steroids plus extra-corporeal photopheresis and itraconazol was replaced by oral voriconazol. He remained very prostrated and 1 month later painless subcutaneous nodules were noted. An excised nodule revelead infiltration of the subcutaneous tissue by hyphae and cultures grew Aspergillus fumigatus. He was apyrexial, non-neutropenic and had no respiratory tract symptoms but a computorised tomography scan showed confluent lung opacities and serum galactomannan was strongly positive. A PET scan revealed numerous lesions involving the limbs, chest wall and lungs. Voriconazol was replaced by Ambisome® and caspofungin in combination, followed by posaconazol and high dose Ambisome® to no avail since the patient died 4 months later.

Disseminated aspergillosis presenting with cutaneous nodules and intact overlying skin is extremely unusual. The PET scan allowed an evaluation of the metastatic infection supporting the interest of this technique in assessing the extent of the disease. Profound immunosuppression and steroid therapy allowed for invasive aspergillosis despite prolonged theoretically protective prophylaxis and adequate neutrophils. The best management of breakthrough invasive aspergillosis in the context of mould-active azole prophylaxis is not known as there are no clinical studies to support an adequate strategy. It should be individualised on the basis of clinical criteria as well as consideration of other antifungal drug classes. Treatment with several antifungal combinations proved ineffective in controlling the infection, emphasizing the need for an increased awareness of invasive fungal infections, even when mould-active antifungal prophylaxis is given.

Session Details

Date: 16/05/2009
Time: 00:00-00:00
Session name: 19th European Congress of Clinical Microbiology and Infectious Diseases
Location: Helsinki, Finland, 16 - 19 May 2009
Presentation type:
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