Med. Mycol. J. Med. Mycol. J. Vol. 55（No. 4）, 2014 E 63 Vol. 55E, E 63 − E 70, 2014 ISSN 2185 − 6486

Case Report Fatal Fungemia with Scedosporium prolificans in a Patient with Acute Myeloid Leukemia

Makoto Nishimoriઃ, Toshio Takahashi઄, Eiko Suzuki઄, Taiichi Kodakaઃ, Nobuhiro Hiramotoઃ, Kiminari Itohઃ, Hiroko Tsunemineઃ, Kyoko Yaritaઅ, Katsuhiko Kameiઅ, Hiroshi Takegawaઆ, Takayuki Takahashiઃ

Departments of Hematology Shinko Hospital, Kobe ઄Laboratory Medicine, Shinko Hospital, Kobe અMedical Mycology Research Center, Chiba University, Chiba આLaboratory Medicine, Kobe City Medical Center General Hospital, Kobe

ABSTRACT

Scedosporium prolificans（S. prolificans）is a type of mold, which rarely affects immunocompromised people. We treated a 71-year-old woman with acute myeloid leukemia（AML-M5a）with low-dose cytarabine, acralubicin, and filgrastim as the induction therapy. On day 7 after the initiation of chemotherapy, she became febrile and agranulocytic, and developed anal pain; therefore, we discontinued the chemotherapy on day 8. Broad-spectrum antibiotics, , and then liposomal were ineffective. The serum concentration of β-D-glucan was 525 pg/mL. She died of multiple organ failure on day 17. S. prolificans was detected from the blood culture on day 13. Physicians should consider Scedosporium spp. when principal agents are ineffective and fungal infection is strongly suspected. Key words：Scedosporium prolificans, acute myeloid leukemia, β-D-glucan, mold

sinuses, or through direct inoculation, such as in Introduction skin puncture 4）. S. prolificans-affected body regions include the blood, lungs, bones, and soft Scedosporium species（spp.）are ubiquitous tissue, and S. prolificans disseminates to multiple fungi, distributed in living environments such as organs in many cases. Although rare, S. prolifi- polluted water and soil, and classified as ascomy- cans infection often causes fatal disease; dissemi- cota in a group of molds 1）. Scedosporium spp. nated disease is particularly associated with a consist of 2 species: Scedosporium prolificans（S. high mortality rate of 87.5% 5）, because active proloficans）and S. apiospermum. S. prolificans antifungal agents against S. prolificans are cur- was first revealed to be pathogenic in 1984, rently not available. Here, we report a patient with although the incidence of infection is very low, acute myeloid leukemia（AML）who developed with 1.33 affected cases per 100,000 people in the fatal fungemia with S. prolificans during induction United States 1,2）. S. prolificans mostly affects chemotherapy for AML. immunocompromised people, such as patients with hematologic diseases 3）. Human infection Case report often results from the inhalation of spores present in the environment into the lungs or paranasal A 71-year-old woman with leukopenia was

Address for correspondence : Takayuki Takahashi Department of Hematology, Shinko Hospital Received : 30, December 2013, Accepted : 19, August 2014 [email protected] E 64 Medical Mycology Journal Volume 55, Number 4, 2014

Table 1．Laboratory findings on admission Hematology Chemistry WBC 1.8×109/L TP 7.1 g/dL Neu 46.8% Alb 4.2 g/dL Eos 0.0% LDH 232 IU/L Bas 0.8% AST 26 IU/L Mon 1.6% ALT 43 IU/L Lym 47.0% ALP 191 IU/L Blast 2.8% T-bil 0.9 mg/dL RBC 3,250×109/L BUN 10.5mg/dL Hb 11.3 g/dL Cre 0.6 mg/dL Ht 32.6% UA 4.5mg/dL Plt 153×109/L Na 143 mEq/L Reti 1.0% K 4.2 mEq/L Coagulation Cl 109 mEq/L Fib 304 mg/dL PT 106% Bone marrow aPTT 32.3 sec Ncc 2.2×104/mL D-dimer 0.4μg/mL Megakaryocytes Decreased Serology M/E ratio 4.55 CRP 0.3 mg/dL Blasts 31.3% MMP-3 63.5ng/mL POX （＋） IgA 293 mg/dL ASD （−） IgG 1,141 mg/dL α-NB （+） IgM 66 mg/dL Karyotype 46, XX MMP-3: matrix metalloproteinase-3（normally 17.3 to 59.7 ng/dL）; POX: peroxidase staining; ASD: naphthol AS-D chloroacetate esterase staining; α-NB: α-naphthyl butyrate esterase staining.

admitted to our hospital because of suspected （normally 870 to 1,700 mg）, and IgM of 66 mg/dL AML. Three years before admission, she had been （normally 46 to 260 mg）, suggesting well-control- diagnosed with rheumatoid arthritis（RA）and led RA and intact humoral immunity. A bone Sjögren>s syndrome. Two years before admission, marrow aspirate showed hypocellularity with a she had been treated with tocilizumab（8 mg/kg, nucleated cell count of 21.1×109/L, in which blast weekly）for the acute exacerbation of RA, with cells comprised 31.1%. Some of these blast cells improvement of the disease. Two months before showed differentiation toward immature mono- admission, she had developed leukopenia（white cytes（Fig. 1A）and were positive for peroxidase cell count: 1.8×109/L）. Therefore, tocilizumab was and α-naphthyl butyrate esterase staining（Fig. discontinued with persistent leukopenia, and a 1B, 1C）. A diagnosis of AML-M5a according to the bone marrow aspirate led to suspected AML. FAB classification was made. Thus, she was referred to our hospital. She had a history of tocilizumab therapy, and Physical and physiological examinations on was thereby suggested to be in an immunocom- admission were unremarkable. Laboratory find- promised state. We, therefore, employed CAG ings on admission are shown in Table 1. The white chemotherapy（low-dose cytarabine, acralubicin, blood cell（WBC）count was 1.8×109/L, with 2.8% and filgrastim）as remission induction therapy for blast cells, 46.8% neutrophils, 1.6% monocytes, AML. The clinical course of the patient is shown in and 47.0% lymphocytes, a hemoglobin concentra- Fig. 2. On day 7 after the initiation of CAG therapy, tion of 11.3 g/dL, and platelet count of 153×109/L. she developed anal pain due to an exacerbated Serological tests revealed C-reactive protein hemorrhoid with fever above 38℃. The hemor- （CRP）of 0.3 mg/dL（normally below 0.3 mg）, rhoid was swollen, reddish, and partially erosive matrix metalloproteinase-3（MMP-3）of63.5ng/dL and hemorrhagic. The WBC count was 0.5×109/L （normally 17.3 to 59.7 ng/dL）, IgA of 293 mg/dL wih 0% neutrophils. We administered tazobac- （normally 110 to 410 mg）, IgG of 1,141 mg/dL tam/piperacillin for the infectious hemorrhoid, Med. Mycol. J. Vol. 55（No. 4）, 2014 E 65

Fig. 1．Smear preparation of a bone marrow aspirate on admission to our hospital. A: Many immature monocytes can be seen. A small number of these abnormal cells show monocytic matura- tion（arrow）（Wright-Giemsa staining, ×1,000）. These leukemic cells are positive for peroxidase staining（B） and α-naphthyl butyrate esterase staining（C）.

which brought about transient resolution of the susceptible to vancomycin, while the culture of fever. On day 8, we discontinued the CAG viscous fluid taken by swabbing from the erosive because of agranulocytosis and a clearly infec- portion of the painful hemorrhoid yielded a tious portion of the painful hemorrhoid. On day 11, negative result. On day 13, however, she became she again became febrile with a body temperature more febrile and developed frequent diarrhea of 38℃ or higher; therefore, we added vancomycin with abdominal tenderness in addition to the anal for possible infection caused by methicillin-resis- pain. We, therefore, added micafungin for possible tant Staphylococcus aureus. On day 12, blood intestinal candidiasis presumably derived from culture yielded Enterococcus faecium which was the infectious hemorrhoid. On day 14, she had a E 66 Medical Mycology Journal Volume 55, Number 4, 2014

Anal pain Fever Peritoneal irritaon CAG WBC Neut (/μL) 5,000 －80 (%) －70 4,000 －60 －50 3,000 －40 2,000 WBC －30 －20 1,000 Neut 䘩 －10

CRP 40 (mg/dL) 30

20 10

5 10 15 17 TAZ/PIPC VCM MCFG MEPM L-AMB Fig. 2． Clinical course of the present patient. CAG: cytarabine, acralubicin, and filgrastim; Neut: neutrophils; TAZ/PIPC: tazobactam/piperacillin; VCM: vancomycin; MCFG: micafungin; MEPM: meropenem; L-AMB: liposomal-amphotericin B.

persistently high fever with peritoneal irritation ing of the pathogens from the blood culture is sign, and a laboratory test showed that the serum shown in Fig 3A. Morphologically, the fungus had concentration of β-D-glucan had elevated to 525 mold-like features, although we could not identify pg/mL（normally below 11 pg/mL）. From this the exact fungal species at that time. The growth time-point, she became drowsy, with a progres- pattern of the fungus in BD difco Potato Dextrose sive deterioration of consciousness. Although we Agar（Nippon Becton Dickinson Co., Ltd., Tokyo, subsequently obtained negative results from Japan）isshown in Fig. 3B. The color of the fungus repeated blood cultures, we changed micafungin colony was blackish to light brown, and it was to liposomal amphotericin B and tazobactam/ covered with whitish filamentous organisms. On piperacillin to meropenem for possible cellophane tape preparation, Scedosporium spp. by micafungin-resistant fungi or multiple-drug-re- was suspected because of the characteristic sistant bacteria, without improvement of her feature of the hyphae（Fig. 3C）. A few weeks later, condition. She developed multiple organ failure this fungus was identified as S. prolificans by and died on day 17. Autopsy was not performed. rRNA sequence analysis 6）, performed at the The day after her death, we received a report that Medical Mycology Research Center, Chiba Uni- a fungus had been grown from blood culture with versity, Chiba, Japan. An in vitro susceptibility a culture bottle（BACTEC Aerobic Plus, but not test 7） of the isolated S. prolificans, performed at BACTEC Anaerobic Plus; Nippon Becton Dickin- the Department of Laboratory Medicine, Kobe son Co., Ltd., Tokyo, Japan）, which was per- City Medical Center General Hospital, Kobe, formed on day 13. The fungus was also grown Japan, showed the minimum inhibitory concentra- from fecal culture performed on day 15, and blood tion（MIC）of amphotericin B, micafungin, vorico- cultures performed on days 14 and 15. Gram-stain- nazole, , , , Med. Mycol. J. Vol. 55（No. 4）, 2014 E 67

Fig. 3 A: Gram-staining of the fungus grown from the blood culture, ×1,000. The smallest scale of the division is one micrometer. Morphologically, the fungus had mold-like features with developing hyphae（arrows）. B: The growth pattern of the fungus in BD difco Potato Dextrose Agar（Nippon Becton Dickinson Co., Ltd., Tokyo, Japan）. C: On cellophane tape preparation, the hyphae had a septum, and the conidium was ovum-shaped, slightly narrowing near the apex, which resulted in the formation of a small apical mass（lactophenol cotton blue staining, ×200）.

and to be 4, ＞16, 8, ＞64, ＞8, ＞16, and tologic diseases such as myeloid leukemia. These ＞64μg/mL, respectively. immunocompromised patients had a poor prog- nosis, while patients without hematologic or Discussion immunologic disorders had a favorable one, with the exception of 2 cases 12, 23）. Interestingly, one of S. prolificans infection is rare, as previously these 2 patients was a drowning 5victim in the described. However in the past 5years, 16 cases tsunami of the Great East Japan Earthquake in of S. prolificans infection have been reported 8−23）. 2011, indicating the presence of S. prolificans in As shown in Table 2, the majority of these 16 muddy water or soil. patients were immunocompromised, having hema- In the present patient, we employed low-intensi- E 68 Medical Mycology Journal Volume 55, Number 4, 2014

Table 2．Cases of Scedosporium prolificans infection in the literature during the past 5years Year of Age/ Antifungal agents Ref. Case Clinical background Fungal infection Outcome report gender administered No. , 35, 1 2009 nonspecific epidural abscess , transient improvement 8 male and 62, 2 2009 nonspecific intervertebral disc voriconazole cure 9 female 38, post-cardiac voriconazole, 3 2010 ocular and fungemia improvement 10 female transplantation terbinafine 28, acute undifferentiated pseudoaneurysm, voriconazole, 4 2010 death 11 female leukemia fungemia terbinafine 50, rheumatic fever in liposomal 5 2010 fungemia death 12 male childhood amphotericin B 29, acute lymphoblastic endocarditis, voriconazole, death after partial 6 2011 13 female leukemia fungemia liposomal amphotericin B improvement 70, acute myeloid , 7 2011 fungemia death 14 male leukemia caspofungin 55, debridement, 8 2011 nonspecific keratitis cure 15 female 83, myelodysplastic voriconazole, 9 2012 fungemia death 16 male syndrome micafungin 10, 10 2013 nonspecific osteomyelitis voriconazole marked improvement 17 male 35, acute myeloblastic voriconazole, 11 2013 fungemia death 18 female leukemia terbinafine voriconazole, 70, post-lung pericarditis, aortic 12 2013 terbinafine, and death 19 female transplantation aneurysm caspofungin 44, multiple focal voriconazole, 13 2013 lung cancer well-controlled 20 male angioinvasion terbinafine itraconazole, 58, 14 2011 MGUS lung liposomal amphotericin death 21 male B, voliconazole 58, acute myeloid 15 2010 fungemia micafungin death 22 female leukemia lung: Tsunami 33, 16 2012 nonspecific following Japan fosfluconazole death 23 female Earthquake 71, acute myeloid micafungin, present case fungemia death female leukemia liposomal amphotericin B MGUS: Monoclonal gammopathy with undetermined significance.

ty chemotherapy（CAG chemotherapy）under the common adverse events were infections, includ- assumption that she was potentially immunocom- ing bacterial pneumonia, sepsis, and viral infec- promised because of her history of tocilizumub tion, indicating that RA patients treated with therapy for RA. Nevertheless, she became agra- tocilizumab have a risk of infections. Furthermore, nulocytic on day 7 after the initiation of CAG 3 risk factors were identified: a history of lung chemotherapy, and subsequently developed bac- disease, prednisolone administration at 5mg/day teremia with Enterococcus faecium and finally or more, and an age of 65or older. Although the fungemia with S. prolificans. This clinical course is present patient had 2 of these 3 risk factors, it is quite exceptional with induction chemotherapy difficult to fully explain her unfavorable clinical for AML with a low-intensity protocol. Regarding course with the risk of infection by tocilizumab. tocilizumab therapy for RA, a large cohort study in We performed antibiotic and antifungal ther- Japan was published 24）. In this report, the most apies according to guidelines for febrile neut- Med. Mycol. J. Vol. 55（No. 4）, 2014 E 69

Table 3．In vivo activity of antifungal agents against Scedosporium spp. S. prolificans S. apiospermum Drug In vivo activity MIC（90％） In vivo activity MIC（90％） Amphotericin B − ＞16（16-＞16） − 16（16-＞16） Miconazole − ＞16-64 − 1（0.5-2） Fluconazole − ＞16 − 32（＞16-＞64） Itraconazole − ＞16（＞16-＞32） − 4（1-＞16） Voriconazole ± 4（4-16） + 0.5（0.125-2） Posaconazole − ＞8-16 + 2（0.25-2） − ＞8-16 + 4（0.125-＞8） ± 2-4 + 1-2 Terbinafine − 16-32 − ＞32-＞16 Micafungin ＞32 − ＞16 Caspofungin − NA − NA Susceptibility of Scedosporium spp. to antifungal agents is shown as + to -. Data were collected from the literature on Scedosporium spp. infection. MIC: minimum inhibitory concentration. NA: not available. Each MIC value is indicated in mg/ml and was cited from the article of reference No.26. ropenia（FN）treatment 25）. However, the timing of activities against S. prolificans 26）. Therefore, the the β-D-glucan test may have been too late（on identification of an effective combination of day 14）, although we had already started micafun- antifungal agents using a checkerboard titration gin on day 13. The test of β-D-glucan is useful to method 26） may be useful. Furthermore, the early predict fungal infection and determine the timing diagnosis of S. prolificans infection and prompt of antifungal treatment. Indeed, a high serum initiation of effective antifungal treatment includ- concentration of β-D-glucan was reported in 3 ing voriconazole, either as monotherapy or com- cases of S. prolificans infection 16,21,23）, as well as in bination therapy, appear to be crucial for immuno- the present patient. compromised patients. Regarding the route or origin of S. prolificans infection in the present patient, the infectious Disclosure hemorrhoid is a possibility because the anal pain persisted throughout the course with fever, The authors have no conflict of interest to although S. prolificans was not detected on disclose. culture of the swollen and erosive hemorrhoid. Aside from the origin of S. prolificans infection, S. References prolificans might have emerged as a microbial substitute after the treatment for bacteremia with 1）Malloch D, Salkin IF: A new species of Scedospor- vancomycin-susceptible Enterococcus faecium. ium associated with osteomyelitis in humans. As for the treatment of S. prolificans infection, Mycotaxon 21: 247-255, 1984. 2）Lamaris GA, Chamilos G, Lewis RE, Safdar A, Raad few effective anti-fungal agents are currently II, Kontoyiannis DP: Scedosporium Infection in a available when compared to those for S. apiosper- Tertiary Care Cancer Center: A Review of 25 mumas, as shown in Table 3. However, voricona- Cases from 1989-2006. Clin Infect Dis 43: 1580-1584, zole may be useful in some cases of S. prolificans 2006. infection based on its minimum inhibitory concen- 3）Maertens J, Lagrou K, Deweerdt H, Surmont I, tration（MIC）against S. prolificans. Furthermore, Verhoef GE, Verhaegen J, Boogaerts MA: Dis- seminated infection by Scedosporium prolificans: the combination of voriconazole and terbinafine an emerging fatality among haematology patients. has been widely used and brought about favor- Case report and review. Ann Hematol 79: 340-344, able outcomes for immunocompetent but not 2000. immunocompromised patients, as shown in Table 4）Wilson CM, O>Rourke EJ, McGinnis MR, Salkin IF: 2. Indeed, in an in vitro study, the combination of Scedosporium inflatum: clinical spectrum of a terbinafine and antifungal agents or that of newly recognized pathogen. J Infect Dis 161: 102- 107, 1990. amphotericin B and exhibited some E 70 Medical Mycology Journal Volume 55, Number 4, 2014

5）Rodriguez-Tudela JL, Berenguer J, Guarro J, JC, Cabrero M, Vázquez L, Calonge M: Fatal Kantarcioglu AS, Horre R, de Hoog GS, Cuenca- disseminated Scedosporium prolificans infection Estrella M: Epidemiology and outcome of Scedos- initiated by ophthalmic involvement in a patient porium prolificans infection, a review of 162 cases. with acute myeloblastic leukemia. Diagn Microbiol Med Mycol 47: 359-370, 2009. Infect Dis 76: 375-378, 2013. 6）Wedde M, Müller D, Tintelnot K, De Hoog GS, Stahl 19）Sayah DM, Schwartz BS, Kukreja J, Singer JP, U: PCR-based identification of clinically relevant Golden JA, Leard LE: Scedosporium prolificans Pseudallescheria/Scedosporium strains. Med pericarditis and mycotic aortic aneurysm in a lung Mycol 36: 61-67, 1998. transplant recipient receiving voriconazole 7）National committee for clinical laboratory stan- prophylaxis. Transpl Infect Dis 15: E70-74, 2013. dards: In Reference method for broth dilution 20）Holmes NE, Trevillyan JM, Kidd SE, Leong TY.-M: antifungal susceptibility testing of filamentous Locally extensive angio-invasive Scedosporium fungi: Approved standard M38-A2, Vol. 28, CLSI, prolificans infection following resection for Wayne, 2008. squamous cell lung carcinoma. Medical Mycology 8）Carod-Artal FJ, Ferreira-Coral L, Mauro-Couto J, Case Report 2: 98-102, 2013. Gomes-E, de Agassiz-Vasques M: Chronic spinal 21）Ohashi R, Kato M, Katsura Y, Takekawa H, epidural abscess caused by Scedosporium prolifi- Hoshika Y, Sugawara T, Yoshimi K, Togo S, cans in an immunocompetent patient. Spine（Phi- Nagaoka T, Seyama K, Takahashi K, Tsuchiya K, la Pa 1976）34: E330-332, 2009. Misawa S, Kikuchi K: Breakthrough lung Scedos- 9）Garcia-Vidal C, Cabellos C, Ayats J, Font F, Ferran porium prolificans infection with multiple cavity E, Fernandez-Viladrich P: Fungal postoperative lesions in a patient receiving voriconazole for spondylodiscitis due to Scedosporium prolificans. probable invasive aspergillosis associated with Spine J 9: e1-7, 2009. monoclonal gammopathy of undetermined signifi- 10）O>Hearn TM, Geiseler PJ, Bhatti RA, Dean E: cance（MGUS）. Med Mycol J 52: 33-38, 2011. Control of disseminated Scedosporium prolificans 22）Kimura M, Maenishi O, Ito H, Ohkusu K: Unique Infection and endophthalmitis. Retinal Cases & histological characteristics of Scedosporium that Brief Reports 4: 18-19, 2010. could aid in its identification. Pathol Int 60: 131-136, 11）Spanevello M, Morris KL, Kennedy GA: 2010. Pseudoaneurysm formation by Scedosporium 23）Hatakeyama Y, Yamada Y, Furukawa K, Narita K, prolificans infection in acute leukaemia. Intern Ishifuji K, Kurota M, Kon H, Yarita K, Kamei K, Med J 40: 793, 2010. Suwabe A: Three Cases of Tsunami Lung in which 12）Ahmad S, Zia S, Sarwari AR: Scedosporium Genus Scedosporium was isolated. The Journal prolificans Endocarditis: Case report and review of Japanese Society for Clinical Microbiology 22: of literature. W V Med J 106: 24-26, 2010. 289-297, 2012. 13）Fernandez Guerrero ML, Askari E, Prieto E, Gadea 24）Koike T, Harigai M, Inokuma S, Ishiguro N, Ryu J, I, Román A: Emerging infectious endocarditis due Takeuchi T, Takei S, Tanaka Y, Ito K, Yamanaka to Scedosporium prolificans: a model of therapeu- H: Postmarketing surveillance of tocilizumab for tic complexity. Eur J Clin Microbiol Infect Dis 30: rheumatoid arthritis in Japan: interim analysis of 1321-1324, 2011. 3881 patients. Ann Rheum Dis 70: 2148-2151, 2011. 14）Rivier A, Perny J, Debourgogne A, Thivillier C, 25）Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Lévy B, Gérard A, Machouart M: Fatal dissemi- Ito JI, Mullen CA, Raad II, Rolston KV, Young JA, nated infection due to Scedosporium prolificans Wingard JR: Clinical practice guideline for the use in a patient with acute myeloid leukemia and of antimicrobial agents in neutropenic patients posaconazole prophylaxis. Leuk Lymphoma 52: with cancer: 2010 update by the infectious dis- 1607-1610, 2011. eases society of America. Clin Infect Dis 52: e56- 15）Chandel LR, Sood A, Chauhan S, Thakur K: Need e93, 2011. to suspect fungal etiology in presumed bacterial 26）Husain S, Muñoz P, Forrest G, Alexander BD, karatitis−A case report of keratitis due to Somani J, Brennan K, Wagener MM, Singh N: Scedosporium prolificans. Asian Journal of Infections due to Scedosporium apiospermum and Medical Sciences 2: 28-30, 2011. Scedosporium prolificans in transplant recipients: 16）Nishio H, Utsumi T, Nakamura Y, Suzuki T, Kamei clinical characteristics and impact of antifungal K, Saitoh T: Fungemia caused by Scedosporium agent therapy on outcome. Clin Infect Dis 40: 89- prolificans in myelodysplasstic syndrome. The 99, 2005. Journal of the Japanese Association for Infec- 27）Cortez KJ, Roilides E, Quiroz-Telles F, Meletiadis tious Diseases 86: 22-26, 2012. J, Antachopoulos C, Knudsen T, Buchanan W, 17）Matlani M, Kaur R, Shweta: A case of Scedospor- Milanovich J, Sutton DA, Fothergill A, Rinaldi MG, ium prolificans osteomyelitis in an immunocompe- Shea YR, Zaoutis T, Kottilil S, Walsh TJ: Infections tent child, misdiagnosed as tubercular caused by Scedosporium spp. Clin Microbiol Rev osteomyelitis. Indian J Dermatol 58: 80-81, 2013. 21: 157-197, 2008. 18）Reinoso R, Carreño E, Hileeto D, Corell A, Pastor