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      Rare case of disseminated fusariosis in a young patient with graft vs. host disease following an allogeneic transplant

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          Abstract

          Fusarium infection is a severe fungal infection caused by fungi of the genus Fusarium. It most commonly occurs in immunocompromised patients with malignant hematological comorbidities or secondary to hematopoietic stem cell transplant. The classical route of contamination is through inhalation but infection may also occur through contiguity with a skin lesion. This report describes the case of a 24-year-old woman who developed graft-vs.-host disease (GVHD) at 220 days after receiving an allogeneic stem cell transplant from a sibling donor for Hodgkin disease. On day 330 after transplant the patient presented with fever and several painful subcutaneous, tender, red nodules with ulcerative and necrotic features on the pelvic region and right leg, extensive glass infiltrative lesions in the lungs and pansinusitis; however, the patient did not have onychomycosis. Following skin biopsy, culture of cutaneous lesions, computed tomography (CT) scanning of the lungs and CT scanning and magnetic resonance imaging of facial sinuses the patient was diagnosed with disseminated Fusarium species infection. Despite intensive treatment with voriconazole, the patient succumbed with respiratory insufficiency on day 400 after transplant. This case is noteworthy because the patient did not have any additional risk associated with the allogeneic transplant; there was no transplant mismatch, no severe neutropenia and no prior clinical signs of onychomycosis. The association of skin lesions with GVHD lesions increased the initial immunosuppression and delayed diagnosis.

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          Most cited references29

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          Epidemiology and outcome of mould infections in hematopoietic stem cell transplant recipients.

          Reports have focused on the emergence of moulds as pathogens in recipients of hematopoietic stem cell transplants. To review the incidence of and risks for mould infections, we examined the records of 5589 patients who underwent hematopoietic stem cell transplantation at the Fred Hutchinson Cancer Research Center (Seattle) from 1985 through 1999. After 1992, the incidence of invasive aspergillosis increased in allograft recipients and remained high through the 1990s. Infections with non-fumigatus Aspergillus species, Fusarium species, and Zygomycetes increased during the late 1990s, especially in patients who received multiple transplants. Although infection caused by Scedosporium species was common in patients who had neutropenia, infection caused by Zygomycetes typically occurred later after transplantation, when patients had graft-versus-host disease. The overall 1-year survival rate was equally poor (similar20%) for all patients with mould infections. The results of the present study demonstrate the changing epidemiology of mould infections, emphasizing the increasing importance of amphotericin B--resistant organisms and the differences in risks and outcome of infection with different filamentous fungi.
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            Cutaneous infection by Fusarium species in healthy and immunocompromised hosts: implications for diagnosis and management.

            Infections by Fusarium species frequently involve the skin, either as the primary or the metastatic site. To better understand the pathophysiology of these infections, 43 new patients with fusariosis were evaluated, and the literature was reviewed. A total of 259 patients (232 immunocompromised and 27 immunocompetent) were identified. Skin involvement was present in 70% of patients, particularly in immunocompromised patients (72% vs. 52%; P=.03). In immunocompetent patients, cutaneous infections were characterized by preceding skin breakdown, localized involvement, slow pace of progression, and good response to therapy. In contrast, skin involvement in immunocompromised patients was only occasionally preceded by skin breakdown and typically was presented as rapidly progressive disseminated lesions at various stages of evolution. Metastatic skin lesions were associated with fungemia, neutropenia, and death. Skin was the single source of diagnosis for the majority of immunocompromised and immunocompetent patients. Recommendations for the prevention of fatal fusariosis originating from skin are presented.
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              Outcome predictors of 84 patients with hematologic malignancies and Fusarium infection.

              Invasive infection by Fusarium sp. is associated with high mortality in patients with hematologic cancer. Yet to the authors' knowledge, little is known regarding predictors of adverse outcome. The authors conducted a retrospective review of the records of patients with hematologic carcinoma and invasive fusariosis who were treated at one institution in the U.S. and at 11 centers in Brazil. The records of 84 patients were evaluated. Neutropenia was present in 83% and 33 patients had undergone stem cell transplantation. Only 18 patients (21%) were alive 90 days after the diagnosis of fusariosis. Multivariate predictors of poor outcome were persistent neutropenia (hazard ratio [HR] of 5.43; 95% confidence interval [95% CI], 2.64-11.11) and use of corticosteroids (HR of 2.18; 95% CI, 1.98-3.96). The actuarial survival rate of patients without any of these factors was 67% compared with 30% for patients who recovered from neutropenia but were receiving corticosteroids and 4% for patients with persistent neutropenia only. None of the patients with both risk factors survived (P<0.0001). Measures to reduce the duration of neutropenia, as well as the judicious use of corticosteroids, may reduce the high mortality rate of fusariosis in patients with hematologic cancer. Copyright 2003 American Cancer Society.
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                Author and article information

                Journal
                Exp Ther Med
                Exp Ther Med
                ETM
                Experimental and Therapeutic Medicine
                D.A. Spandidos
                1792-0981
                1792-1015
                October 2016
                01 August 2016
                01 August 2016
                : 12
                : 4
                : 2078-2082
                Affiliations
                [1 ]Bone Marrow Transplant Center, Fundeni Clinical Institute, 022328 Bucharest, Romania
                [2 ]Department of Surgery, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
                [3 ]Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
                [4 ]Department of Dermatology, University of Medicine and Pharmacy ‘Gr. T. Popa’, 700115 Iasi, Romania
                [5 ]Department of Clinical Pharmacy, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
                [6 ]Department of Toxicology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
                [7 ]Laboratory of Toxicology, Medical School, University of Crete, Voutes, Heraklion, 71409 Crete, Greece
                [8 ]Department of Dermatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
                Author notes
                Correspondence to: Professor Daciana Elena Branisteanu, Department of Dermatology, University of Medicine and Pharmacy ‘Gr. T. Popa’, 16 Universitatii Street, 700115 Iasi, Romania, E-mail: debranisteanu@ 123456yahoo.com
                [*]

                Contributed equally

                Article
                ETM-0-0-3562
                10.3892/etm.2016.3562
                5038475
                27698695
                bea25a1d-777c-4d75-abb8-77a257e939f0
                Copyright: © Tanase et al.

                This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

                History
                : 12 December 2015
                : 23 March 2016
                Categories
                Articles

                Medicine
                fusariosis,immunosuppression,allogeneic stem cell transplant
                Medicine
                fusariosis, immunosuppression, allogeneic stem cell transplant

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