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  • raas inhibitor Skin involvement is present in of cases

    2019-05-13

    Skin involvement is present in 68–70% of cases of fusariosis [5]. As skin is one of the primary sources of entry, thorough skin examination and biopsy of suspicious nodules should be considered. Sinus involvement occurs in 80% of cases of disseminated fusariosis, with manifestations including facial or periorbital cellulitis and sinus congestion [6]. Pulmonary nodules have been reported in 80% of patients with respiratory symptoms, with a range in diameter from 0.3cm to 2.7cm [7]. Nodules greater than 1cm should raise the suspicion for invasive fungal infection [8]. The role of galactomannan and (1→3)-β-D-glucan testing in fusariosis is unknown. A positive (1→3)-β-D-glucan test combined with a negative galactomannan is thought to favor diagnosis of other hyalohyphomycosis but aspergillosis [1]. Exposure to raas inhibitor or antifungals can cause variable sensitivity to galactomannan and/or (1→3)-β-D-glucan tests [9]. Antifungal susceptibility testing is recommended, however, there is lack of clear evidence to support the relation between fungal susceptibilities and clinical efficacy [1]. Host factors that predict poor outcomes of Fusarium infection in patients with hematological malignancies are prolonged profound neutropenia (> 14 days and < 100/mm3, respectively) and therapy with corticosteroids [6]. Colony stimulating factors have a role in the treatment of life-threatening infections due to chemotherapy-associated neutropenia, and in shortening the duration of prolonged neutropenia to reduce the incidence of febrile neutropenia [10]. However, these agents should be used with caution in patients with active AML to avoid stimulation of leukemic blast proliferation [11]. Our case report provides further evidence that pre-existing fungal infections should not preclude SCT for hematologic malignancies [12]. For this patient, the short time to engraftment, in combination with granulocyte infusions minimized the duration of post-transplant neutropenia, which helped control the Fusarium infection. A multi-disciplinary approach with involvement of the Hematology, Infectious Disease and Transfusion Medicine services to maintain adequate neutrophil counts prior to engraftment was successful in this case. Granulocyte infusions have become less complicated and more effective using HLA- matched donors [13]. Mobilization regimens including G-CSF and dexamethasone have increased granulocyte yield to more than 0.6 × 109/kg [12]. Disseminated Fusarium solani in immunocompromised patients has a high mortality rate, is typically refractory to anti-fungal treatment, and adequate neutrophil counts appear to be an important determinant of survival [1]. Successful outcomes, as in the case, are underreported in the literature. This case illustrates the early detection, successful interventions and outcome for a systemic invasive fungal infection that is typically fatal. We used thorough skin examinations, early diagnostic interventions, (1→3)-β-D-glucan serum monitoring during treatment, serial CT scans, G-CSF to expedite neutrophil recovery and granulocyte infusions to minimize duration of peri-transplant neutropenia. Adequate neutrophil counts were critical to the management of this invasive fungal infection and allowed for successful definitive treatment of relapsed AML.
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    Introduction Myeloid Sarcoma (MS) is a rare entity characterized by the proliferation of immature myeloid cells in extramedullary sites. The 2008 WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues and its updated 2016 version clarified the diagnosis of MS as “a tumor mass consisting of myeloid blasts with or without maturation occurring at an anatomic site other than the bone marrow” [1,2]. A predilection for males (male: female ratio = 1.2:1) is reported, with a median age at diagnosis of 56 years [3].