SESSION TITLE: Pneumonia and Pneumonitis
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Sunday, October 27, 2013 at 04:15 PM - 05:15 PM
INTRODUCTION: Patients with prolonged neutropenia are susceptible to invasive fungal infections, most commonly caused by candida and aspergillus. Rare molds have also been implicated in lung infections of immunocompromised hosts. We report a case of Paecilomyces lilacinus pneumonia responsible for febrile neutropenia.
CASE PRESENTATION: 48-year-old male presented with subacute dyspnea on exertion. He was found to be pancytopenic, and bone marrow biopsy was diagnostic of acute lymphoblastic leukemia. Following completion of induction chemotherapy, he developed neutropenic fevers that continued despite a 2-week course of broad-spectrum anti-bacterial agents. The patient then began complaining of a non-productive cough. Chest computed tomography (CT) revealed an infiltrate in the left lower lobe (Fig 1A), and anti-microbial coverage was broadened to include voriconazole. Neutropenia, fevers, and cough persisted, but he was saturating well on ambient air. Physical examination revealed unlabored respiration with crackles and egophony at the left base. Chest XRay and repeat CT are shown in Fig 1B-C. Bronchoalveolar lavage (BAL) yielded cytological and microbiological findings consistent with P. lilacinus (Fig 2). Therapy was changed to posaconazole with resolution of fever and infiltrate.
DISCUSSION: Paecilomyces lilacinus is a saprophytic mold similar to Penicillium found in soil and known to cause human infections since the 1950s, mostly involving the eye, skin, and subcutaneous tissues. The majority of reported cases have occurred in the setting of impaired immunity. The first report of thoracic involvement dates to a case of P. lilacinus empyema in the 1970s. In all previously reported thoracic cases, definitive diagnosis was made by morphological examination of a culture specimen; care must be exercised to distinguish Paecilomyces species from Penicillium. Sensitivity to older azole therapy, especially in the case of P. lilacinus, is limited, making amphotericin B the traditional choice.
CONCLUSIONS: Besides the usual opportunistic molds with known sensitivity to conventional antifungal agents, uncommon pathogens such as P. lilacinus need to be considered when a profoundly immunosuppressed patient with pneumonia fails to improve despite conventional broad-spectrum azole therapy. Newest azoles, such as posaconazole, may have superior activity against this rare mold, thereby obviating the risk of amphotericin therapy or surgical intervention.
Reference #1: 1. Ono N, Sato K, Yokomise H, Tamura K. Lung abscess caused by Paecilomyces lilacinus.Respiration. 1999;66(1):85-7.
Reference #2: 2. Pastor FJ, Guarro J.Clinical manifestations, treatment and outcome of Paecilomyces lilacinus infections.Clin Microbiol Infect. 2006 Oct;12(10):948-60.
Reference #3: 3. Mullane K, Toor AA, Kalnicky C, Rodriguez T, Klein J, Stiff P. Posaconazole salvage therapy allows successful allogeneic hematopoietic stem cell transplantation in patients with refractory invasive mold infections.Transpl Infect Dis. 2007 Jun;9(2):89-96.
DISCLOSURE: The following authors have nothing to disclose: Steven Hobson, Oleg Epelbaum, Anatoly Leytin, MD
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