SESSION TYPE: Infectious Disease Student/Resident Cases
PRESENTED ON: Tuesday, October 23, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: Fusarium species are angioinvasive molds that live in soil and can cause infection through inhalation of the airborne pathogen or by entry through the skin such as in patients with preexisting onychomycosis.
CASE PRESENTATION: A 53-year-old man presented with six weeks of worsening weakness, dizziness, lethargy, and dyspnea on minimal exertion with occasional low-grade fevers, night sweats and chills. He lost 13 pounds over 14 months and denied any bruising, bleeding, or gingival hypertrophy. Physical exam showed no onychomycosis. Laboratory data showed hemoglobin 7.3g/dL, platelets 12 x109/L, and WBC 2.0 x109/L with 5% neutrophils, 1% bands, 93% lymphocytes. Bone marrow biopsy revealed 50% blasts with no Auer rods but a few pseudoPelger Huet Cells and hypercellularity of 80%. The patient was diagnosed with acute myeloid leukemia (AML) with complex cytogenetics, and received induction chemotherapy with cytarabine and idarubicin. One day after completion of induction chemotherapy (Day 1), the patient started to have nightly fevers. Laboratory testing showed WBC 0.6 x109/L with absolute neutrophil count of zero. Cultures of blood, urine, and a chest x-ray were negative. Cefepime, vancomycin, acyclovir and fluconazole were started for neutropenic fever. Bone marrow biopsy on day 5 demonstrated failure of induction chemotherapy. The patient continued to have nightly fevers without any respiratory symptoms. On day 12, CT chest revealed bilateral round pulmonary infiltrates and a 4.7 cm mass in the posterior segment of the right upper lobe with central lucency and surrounding ground glass opacities consistent with the halo sign. Liposomal amphotericin B was started. Bronchioalveolar lavage and brushings on day 14 revealed Fusarium species, and voriconazole was added. The patient died on day 50.
DISCUSSION: Fusariosis should be considered in immunosuppressed patients with hematologic malignancies who develop fevers despite antibiotic therapy for neutropenic fever, develop characteristic cutaneous lesions, or develop new pulmonary or sinus symptoms. CT scan of the chest is the initial test of choice as all patients with pulmonary fusariosis have an abnormal chest CT with 82% of patients demonstrating a nodule or mass, whereas only 45% of patients have an abnormal chest x-ray.
CONCLUSIONS: Although the halo sign (ground-glass opacities surrounding a mass or nodule) can be seen with angioinvasive molds such as aspergillosis and zygomycosis, this is the first reported case to show the halo sign on CT in a patient with pulmonary fusariosis.
1) Wabh H et al. (2008). Reversed Halo Sign in Invasive Pulmonary Fungal Infection. Oxford Journals 2008; 46(11): 1733-1737.
DISCLOSURE: The following authors have nothing to disclose: Prateek Sanghera, Victor Test, Erik Wallace
No Product/Research Disclosure InformationThe University of Oklahoma School of Community Medicine, Tulsa, OK