Critical Care: Student/Resident Case Report Poster - Critical Care II |

Disseminated Fusarium in a Patient With Acute Myeloid Leukemia FREE TO VIEW

Nicholas Villalobos, MD; Benjamin Deaton, MD; Andrew Judd, MD; Erik Kraai, MD
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UNMSOM Department of Pulmonary, Critical Care, and Sleep Medicine, Albuquerque, NM

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):395A. doi:10.1016/j.chest.2016.08.408
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION:Fusarium infection is an uncommon pathogen in critically ill patients. However, it should be considered in any immunocompromised patient. We describe a patient with acute myeloid leukemia (AML) presenting with disseminated Fusarium infection.

CASE PRESENTATION: A 73-year-old man with a history of AML and prior treatment with azacitidine was admitted to for induction chemotherapy with fludarabine and cytarabine. The patient was on prophylactic antibiotics including acyclovir, ciprofloxacin, and posaconazole. He began having sinus headaches a few days into his admission which did not resolve with loratidine and saline rinses. On chemotherapy day 6, a maxillofacial CT was performed and was concerning for chronic sinusitis and amoxicillin-clavulanate was started. Several days later, MR of the facial sinuses revealed signs of invasive fungal infection. He underwent surgical debridement. On days 10 and 11, mold was isolated from tissue samples obtained during surgery and he was started on Amphotericin-B. Voriconazole was added on day 13 when blood cultures returned positive for Fusarium sp. On day 17, he was scheduled for further debridement, but became febrile, hypotensive, and tachypneic. He was transferred to the intensive care unit with disseminated Fusarium and multiorgan failure. On exam, he was ill appearing, with several small, inflamed, purple plaques 1-3 cm in diameter in various locations on his body. He deteriorated further and was changed to comfort care by family and expired.

DISCUSSION: While rare, disseminated fusariosis is most common in hematologic malignancy, transplant recipients, or prolonged neutropenia. While Fusarium is ubiquitous in the environment, the prevalence of invasive infection is quite low, estimated at only 0.13% of patients with hematologic malignancies. Additionally, our patient developed fusariosis while on posaconazole prophylaxis, which is a known phenomenon. His presentation was typical of disseminated disease with characteristic skin lesions (small, purple plaques) and sinus infection. Treatment is difficult and mortality, while not defined, has been described as very high. Resistance to anitfungals is common. Unfortunately, no studies exist of direct comparison of antifungals or duration in the treatment of Fusarium. Some experts suggest combination therapy of voriconazole and amphotericin B for at least 12 weeks and until immunosuppression has improved.

CONCLUSIONS:Fusarium is an uncommon pathogen in humans, though it is common in the environment. Immunocompromised patients are most at risk of disseminated infection in which mortality is high.

Reference #1: Nucci F, et al. Semin Respir Crit Care Med 2015; 36:706-714.

Reference #2: C. C. Blyth, et al. Consensus guidelines for the treatment of invasive mould infections in haematological malignancy and haemopoietic stem cell transplantation, 2014.Internal Medicine Journal. 2014; 44: 1333-49.

DISCLOSURE: The following authors have nothing to disclose: Nicholas Villalobos, Benjamin Deaton, Andrew Judd, Erik Kraai

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