Disseminated fungal infection caused by Fusarium oxysporum in Acute Myeloid Leukaemia (AML) patient admitted in tertiary cancer centre in North India

 

 

Abstract              Background: Fungal infections caused by Fusarium species usually manifest as cutaneous lesions. Disseminated infections like bloodstream infections occur mainly in immunocompromised and cancer patients if not diagnosed early in these patients. Delay in diagnosis and treatment further complicates the disease severity in the form of increased comorbidity and mortality specially in cancer patients. This is a case report of an Acute Myeloid Leukaemia (AML) patient who succumbed to death after having disseminated Fusarium infection.

Key words: Fusarium, acute myeloid leukemia, skin scrapings.

 

INTRODUCTION

Fusarium causes hyalohyphomycosis causing morbidity and mortality among immunocompromised patients. A wide variety of local, superficial/disseminated human infections are caused by Fusarium species.¹ Patients with prolonged neutropenia and/or severe T-cell immunodeficiency and hematologic malignancies are predisposed for disseminated Fusarium infection.² Such infections are more common and have increased mortality in immunocompromised patients.³

CASE REPORT

A 17-year-old young male came to Out-Patient-Department in Homi-Bhabha-Cancer-hospital, Varanasi (A unit of Tata Memorial centre, Mumbai) with chief complains of low-grade fever and generalised body weakness for past 2-3 months. There was no history of cough, breathlessnes body rashes or any other significant finding. Routine investigations were done, Complete Blood Count (CBC) showed pancytopenia (haemoglobin 7.3g/dL, WBC 400/L) and neutropenia (1000/microL). Confirmation of Acute Myeloid Leukaemia done by Bone Marrow Aspirate was sent to the hematology lab for flow cytometry confirmation of diagnosis. Medical treatment was started in the form of chemotherapy with Cytarabine and Idarubicin was started. After chemotherapy the patient was discharged. On post chemotherapy day 19, the patient came into the Emergency Department with respiratory distress, high grade fever (102℉) and multiple rashes all over the body. Skin rashes were in the form of multiple tender erythematous papules and nodules, which developed in the subsequently in upper and lower extremities, subsequently followed by involvement of the face and neck. Patient was shifted to Bone Marrow Transplant unit (BMT) unit maintaining on oxygen and was hemodynamically stable. Skin scrapings from lesions were sent to the Microbiology Department for the KOH mount and fungal culture. A 10% potassium hydroxide wet mount of skin scrapings revealed septate, hyaline and branched fungal hyphae. The specimen was cultured on Sabouraud Dextrose agar, incubated at 37°C and 25°C. After 5 days of incubation, significant growth of fungal colonies was seen at 25°C in the form of white and cotton obverse and orange reverse suggestive of Fusarium species. Slide culture was performed on Potato Dextrose agar. Lactophenol Cotton Blue mount showed septate, branched hyphae producing microconidia (oval small 2–4 × 4–8 μm with 1–2‑celled conidia singly and in clusters) and many branched conidiophores with phialides producing 2–4 × 11–60 μm multiseptate (3–4), sickle or boat‑shaped macroconidia [Figure 2] Patient was started with injection corticosteroids 1mg/kg/day, Meropenem 1gm TDS and Voriconazole 200mg/day. In spite of above treatment patient did not respond and persistently had high grade fever with chills. Blood culture was also sent in Bactec Automated bottles which flashed positive after 2 days of incubation. Blood culture was performed on Blood agar and MacConkey agar which showed white cottony growth which was sub-cultured on Sabouraud Dextrose agar, incubated at 37°C and 25°C. Fusarium oxysporum was confirmed on the basis of slide culture on potato dextrose agar. Amphotericin B Lipid Complex (ABLC) (5 mg/kg of body weight/day) was added along with Posaconazole in patient treatment regimen along with maintenance dose of 300 mg IV once a day was given. Disseminated nature of infection was confirmed by unrelenting fever and extensive skin lesions (Figure 1) unresponsive to therapy. Patient did not respond to the treatment, was shifted to ICU where the patient was intubated in view of his worsening condition. Patient succumbed to disseminated fungal sepsis after 4 days of admission in ICU.

 

DISCUSSION

A wide variety of local, superficial/disseminated human infections are caused by Fusarium species. Immune status of the host and source of infection determines clinical presentation of Fusarium infection.¹ Skin involvement represents a frequent manifestation (>50%) of infection by Fusarium species and is also the most common source of diagnostic material Most commonly skin is involved first in these infections and skin specimens are commonly used for diagnosis.⁴ Among cancer patients, Aspergillus species is most common invasive fungal infection followed by Fusarium species.⁵ Patients with prolonged neutropenia and/or severe T-cell immunodeficiency are predisposed for disseminated Fusarium infection.² Clinical presentation of our patient was similar to that described in various previous reports. Skin lesion is the most common presentation in immunocompromised patients with disseminated Fusarium infection.⁵ In our patient severe neutropenia contributed as high risk for developing disseminated infection. Patients with disseminated Fusarium infection commonly present with persistent fever, neutropenia, skin lesions and positive blood culture.⁶ Similar findings were seen in our patient. Caspofungin is recommended empirically for patients with persistent febrile neutropenia followed by liposomal Amphotericin B as an alternative choice.⁷ Diagnosis of Fusarium infection on basis of histopathology can be confused with other fungal infections like Aspergillus.⁸ Hence early diagnosis is a big challenge in such patients. Survival rate is only 4% in patients with Fusarium infection.⁹ Table 1 shows outcome of AML patients in different studies. In the current case, the patient was treated with Amphotericin B plus Voriconazole in combination however the patient succumbed to death. The current case emphasizes the importance of early and rapid diagnosis of the systemic Fusarium infection in the immunodeficient patients and prompt initiation of antifungal treatment for their successful outcome.

 

 

 

 

 

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