Oya Shuki, Muta Tsuyoshi
Department of Hematology/Oncology, Japan Community Healthcare Organization Kyushu Hospital, Kitakyushu, Japan.
Division of Hematology and Oncology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan.
Int J Hematol. 2018 Nov;108(5):558-563. doi: 10.1007/s12185-018-2481-8. Epub 2018 Jun 20.
We experienced a breakthrough fungal infection caused by Geotrichum capitatum during empirical therapy with caspofungin. A 68-year-old male patient with refractory acute lymphoblastic leukemia had received umbilical cord blood transplantation after two courses of induction therapy. Empirical therapy with caspofungin was initiated 5 days before transplantation. Tacrolimus was continuously infused to prevent graft-versus-host disease. A minidose of methotrexate was intravenously administered on days 1 and 3 post-transplantation, which was changed to prednisolone from day 7 due to severe mucositis. During a recurrence of fever on day 11, blood cultures were found to be positive for a yeast-like organism, which was later confirmed by mass spectrometry to be G. capitatum. The serum levels of beta-D-glucan were elevated to 747 pg/mL. Caspofungin was switched to liposomal amphotericin B; however, radiological findings revealed pulmonary, splenic, and central nervous system involvement. Progressive renal and hepatic dysfunction subsequently developed. The patient died on day 25 post-transplantation secondary to the development of hemophagocytic syndrome and respiratory failure. We emphasize that recurrent febrile episodes, prolonged neutropenia, and underlying gastrointestinal mucosal damage require extreme caution due to the possibility of breakthrough infection caused by new fungal pathogens during empirical therapy with caspofungin.
我们在使用卡泊芬净进行经验性治疗期间经历了由头状地霉引起的突破性真菌感染。一名68岁患有难治性急性淋巴细胞白血病的男性患者在接受两个疗程的诱导治疗后接受了脐带血移植。在移植前5天开始使用卡泊芬净进行经验性治疗。持续输注他克莫司以预防移植物抗宿主病。移植后第1天和第3天静脉注射小剂量甲氨蝶呤，由于严重的粘膜炎，从第7天起改为泼尼松龙。在第11天发热复发期间，血培养发现一种酵母样生物体呈阳性，后来通过质谱法确认为头状地霉。β-D-葡聚糖血清水平升高至747 pg/mL。卡泊芬净换为脂质体两性霉素B；然而，影像学检查发现肺部、脾脏和中枢神经系统受累。随后出现进行性肾和肝功能障碍。患者在移植后第25天死于噬血细胞综合征和呼吸衰竭。我们强调，由于在使用卡泊芬净进行经验性治疗期间可能出现由新的真菌病原体引起的突破性感染，反复发热发作、长期中性粒细胞减少和潜在的胃肠道粘膜损伤需要格外谨慎。
