ABSTRACT
Invasive aspergillosis is an increasing problem in immuno-incompetent patients after prolonged steroid therapy, cancer radio-chemotherapy, and bone marrow or solid organ transplantation. Cerebral aspergillosis is a well-described complication of the invasive aspergillosis but only in rare cases, the brain is the sole site of infection. Despite increasing availability of antifungal drugs, the prognosis of cerebral aspergillosis is poor. We report on an 11-year-old boy with medulloblastoma in the area of the fourth ventricle. Following tumor surgery and radio-chemotherapy, several abscess-like structures occurred in the operating field. After incomplete abscess, resection histology and culture confirmed a localized Aspergillus fumigatus infection. The initial treatment of the Aspergillus fumigatus infection with conventional amphotericin B failed, and treatment with the triazole voriconazole was started. Intravenous treatment with voriconazole resulted in a reduction of the Aspergillus fumigatus abscess. After switching to oral ambulatory therapy, the Aspergillus fumigatus abscess increased in size. To improve treatment, voriconazole dosage was adapted to reach drug concentrations in cerebrospinal fluid (CSF) above the minimal fungicidal concentration and plasma specimens. During the concentration-controlled voriconazole therapy for a period of 18 months, a complete response was achieved.
Subject(s)
Antifungal Agents/therapeutic use , Aspergillus fumigatus , Brain Abscess/drug therapy , Cerebral Ventricle Neoplasms/complications , Medulloblastoma/complications , Neuroaspergillosis/drug therapy , Pyrimidines/therapeutic use , Surgical Wound Infection/drug therapy , Triazoles/therapeutic use , Administration, Oral , Antifungal Agents/administration & dosage , Antifungal Agents/cerebrospinal fluid , Antifungal Agents/pharmacology , Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Aspergillus fumigatus/drug effects , Brain Abscess/diagnosis , Brain Abscess/etiology , Brain Abscess/microbiology , Carboplatin/administration & dosage , Cerebral Ventricle Neoplasms/drug therapy , Cerebral Ventricle Neoplasms/radiotherapy , Cerebral Ventricle Neoplasms/surgery , Child , Combined Modality Therapy , Cranial Irradiation , Craniotomy , Cyclophosphamide/administration & dosage , Diagnostic Errors , Etoposide/administration & dosage , Humans , Immunocompromised Host , Infusions, Intravenous , Lomustine/administration & dosage , Male , Medulloblastoma/drug therapy , Medulloblastoma/radiotherapy , Medulloblastoma/surgery , Methotrexate/administration & dosage , Neoplasm Recurrence, Local/diagnosis , Neuroaspergillosis/complications , Neuroaspergillosis/diagnosis , Pyrimidines/administration & dosage , Pyrimidines/cerebrospinal fluid , Pyrimidines/pharmacology , Surgical Wound Infection/etiology , Triazoles/administration & dosage , Triazoles/cerebrospinal fluid , Triazoles/pharmacology , Vincristine/administration & dosage , VoriconazoleABSTRACT
Fungal infections are a major cause of morbidity and mortality in patients during chemotherapeutic treatments and malignant hematologic disease. We present a case of a double fungal infection with disseminated Acremonium strictum (A. strictum) and pulmonary Aspergillus fumigatus (A. fumigatus) and its rapid clinical course. A 17-year-old boy with prolonged neutropenia developed a disseminated fungal infection during induction chemotherapy of his acute lymphoblastic leukemia. The infection was rapidly lethal despite neutrophil recovery and early antifungal combination therapy with amphotericin B and caspofungin. Since there are only a few reports about invasive Acremonium infections, we present this case with regard to differences in the clinic pathologic features of Aspergillosis and other opportunistic fungal infections due to Fusarium or Acremonium species.
