Bone Marrow Transplantation, (1999) 24, 417–420  1999 Stockton Press All rights reserved 0268–3369/99 $15.00 http://www.stockton-press.co.uk/bmt Case report Combined anti-fungal therapy and surgical resection as treatment of pulmonary zygomycosis in allogeneic bone marrow transplantation

X Leleu1, B Sendid2, J Fruit2, H Sarre1, E Wattel1, C Rose3, F Bauters1, T Facon1 and JP Jouet1

1Service des Maladies du Sang and 2Laboratoire de Parasitologie-Mycologie, Hoˆpital Huriez, CHRU de Lille; and 3Service d’He´matologie, Hoˆpital St Vincent, Lille, France

Summary: pathology, but can cause aggressive and fulminant disease in immunosuppressed patients. We report a case of mucor- Opportunistic fungal infection is a rare but severe com- mycosis localized to the lung with invasion of blood vessels plication in allogeneic bone marrow transplant (BMT) by hyphae, resulting in tissue necrosis and hemorrhage, recipients. We report a 49-year-old patient who developing within 100 days, in a 49-year-old man who developed pneumonitis after BMT, due to a Mucorales underwent allogeneic BMT. Fungus was observed on bron- fungus (class Zygomycetes), Absidia corymbifera. Infec- chial lavage (BAL) and in histological samples after surgi- tions due to mucormycosis are likely to become increas- cal resection, identified by mycological examinations and ingly recognized even though the occurrence after BMT cultures. Infection caused by Absidia corymbifera is has only been described sporadically. We postulate that exceedingly rare, accounting for less than 1% of reported the patient was contaminated before BMT despite no cases,3 and has never been documented isolated to the lung. intensive drug treatment or other iatrogenic features, We confirm the importance of rapid treatment with i.v. lipo- related to his poor living conditions and developed the somal amphotericin B and growth factors (GM-CSF) in infection during aplasia. He immediately received i.v. combination with surgical management to improve local liposomal amphotericin B (AmBisome) and GM-CSF. control. Unfortunately, despite the initial clinical improve- Because there was no response, the infected area and ment and the absence of Mucor on mycological examin- necrotic tissue were resected. Despite initial clinical and ation after surgery, the patient died 3 weeks later from a biological improvement and the absence of Mucor on bilateral pulmonary infection and multi-organ failure. mycological examination post-surgery, the patient died 3 weeks later from bilateral pulmonary infection and multiorgan failure. Case report Keywords: mucormycosis; Absidia corymbifera; Candida glabrata; bone marrow transplant; AmBisome; A 49-year-old unemployed man of poor social background granulocyte–monocyte colony-stimulating factor was diagnosed with Ph1-negative chronic myelogenous leu- kemia (CML). He was first treated with interferon and hyd- roxyurea, with no reduction in the size of the spleen and white blood count (WBC). Allogeneic BMT was performed Opportunistic fungal infections frequently occur in hema- from his HLA-identical sister after conditioning with cyclo- tology patients and are usually due to yeast, mostly Can- phosphamide and busulfan. Cyclosporine and methotrexate dida. Infection by filamentous fungi is rare but serious, were used as graft-versus-host disease (GVHD) prophy- 1 especially when due to Aspergillus. Mucormycosis occurs laxis. He was isolated in a HEPA-filtered room from day infrequently compared to aspergillosis, but has the same −1 prior to transplant and received prophylactic systemic poor prognosis and the same risk factors in patients sever- anti-fungal treatment with intravenous fluconazole ely immunosuppressed with hematological malignancies (100 mg/day). and receiving a BMT. Even though its occurrence after On day +15, when the WBC was 0.1 × 109/l a non-spe- BMT has only been described sporadically, recently, cific focal febrile pneumonitis of the lower right lung with mucormycosis has been increasingly recognized, and is a pleural effusion was diagnosed clinically. Sputum and 2 usually due to Rhizopus arrhizus. Absidia corymbifera,an blood cultures were repeatedly negative, and stool cultures ubiquitous opportunistic fungal agent, is the only patho- remained positive for Candida glabrata. He was started on genic mould of Absidia genera. In immunocompetent hosts, piperacillin-tazobactam and amikacine. On day +17 he had the hyphae and spores of mucormycosis cause negligible a recurrent fever. Chest radiography remained unchanged, and sputum and blood cultures were still negative; vanco- Correspondence: Dr X Leleu, Service des Maladies du Sang, Hoˆpital Hur- mycin was added. iez, CH et U Lille, 59037, Lille, France On day +20, bronchoscopy with BAL was performed. Received 16 June 1998; accepted 30 October 1998 Direct examination after centrifugation of the BAL was Anti-fungal therapy and surgical resection for zygomycosis X Leleu et al 418

Figure 1 Irregular and broad hyphae without septa on direct examination Figure 3 High resolution enhanced pulmonary chest CT scan showing of BAL smear stained with toluidine blue (original magnification ×400). extensive infiltrating tissue in the right lower lobe which extends out to the pleural surface, complicated by invasion of the vasculature.

Figure 2 Microscopic view of Absidia corymbifera colonies: sporange Figure 4 High resolution enhanced mediastinal CT scan, realised 8 days is typically pyriform in shape with a pronounced apophysis (original mag- after Figure 3, showing a very typical infiltrative lesion in the right lower nification ×400). lobe, before surgery.

On day +21, an enhanced pulmonary (Figure 3) and mediastinal chest CT scan was performed which confirmed negative. However, cultures showed broad, septate hyphae the focal unilateral lesion with bilateral pleural effusions. (Figure 1) which grew on Sabouraud agar media with anti- It also showed invasion of the vasculature with necrotic bacterial antibiotics. The culture plates were incubated at tissue indicating a high risk of vascular rupture. Cerebral 25 and 37°C. Colonies were fast growing, initially white, CT scan was normal but abdominal scan showed splenic becoming pale gray after 1 week. Spongiophores were hya- infarcts. line, single or sometimes branched, arising from the sto- CT of the chest was repeated every 2 days and showed lons, in groups of three, or in whorls of up to five. Sporan- no evolution with a persisting high risk of hemorragic gia were typically pyriform in shape with a characteristic infarction and sudden death (Figure 4). Thus, despite severe conical-shaped columella and pronounced apophysis pancytopenia (WBC at 0.2 × 109/l, hemoglobin at 8 g/dl, (Figure 2). All of these characteristics suggested a diagnosis and 50 × 109/l platelets, and moderate renal failure) exten- of Absidia corymbifera.ACandida glabrata was also iso- sive surgery to resect the right middle and lower lobes was lated from the BAL, and identified by API 32 C system carried out on day 30. Histological examination and myco- (Bio-Me´rieux, Lyon, France). In vitro antifungal suscepti- logical culture of biopsies, confirmed the diagnosis of zygo- bility testing was performed using a micromethod accord- mycosis due to Absidia corymbifera, together with Candida ing to NCCLS recommendations. This showed sensitivity glabrata. The patient remained in the post-surgical inten- to Amphotericin B (MIC Ͻ1.25 ␮g/ml), but resistance to sive care ward receiving liposomal amphotericin B and azoles agents. No mould was found in the pleural effusion. GM-CSF. He was clinically stable, and his WBC reached Intravenous liposomal amphotericin B (5 mg/kg/day) was 1.5 × 109/l, and absolute granulocyte count 0.5 × 109/l, with started on day +20 along with intravenous granulocyte– correction of the renal parameters. monocyte colony-stimulating factor (GM-CSF), to hasten On day +45, an extensive right lung pneumonitis reap- neutrophil and macrophage recovery. peared, confirmed on chest radiography, without recurrence Anti-fungal therapy and surgical resection for zygomycosis X Leleu et al 419 of Mucormycosis on the second BAL. However, Candida As previously reported,5 effective systemic anti-fungal glabrata persisted. He had a delayed recovery of his neutro- treatment was rapidly administered (i.v. liposomal ampho- phils together with renal insufficiency and liver abnormali- tericin B (5 mg/kg per day)), to allow better penetration ties. Ventilation was required. He died on day +52 from into cells6 and the possibility of increasing the dose with a multi-organ failure with bilateral infection of the lungs; reduced chance of side-effects and kidney failure.7 We also autopsy was not undertaken. gave granulocyte–monocyte colony-stimulating factor (GM-CSF) to hasten neutrophil and macrophage recovery and stimulate macrophage function against fungi. Multiple Discussion studies have shown that despite the introduction of numer- ous agents with definite antifungal activity, little success Absidia corymbifera, the only pathogenic fungus of the has, as yet, been seen in the treatment of mycoses such as Absidia genera, is an ubiquitous opportunistic agent from Aspergillosis or Mucormycosis. Some cases8,9 have illus- the order Mucorales (class Zygomycetes), found in air, soil trated that anatomical resection may improve local disease and food. In this case, the origin of the infection was control and can be carried out with an acceptable risk, unknown; thus we postulated that this patient had a pre- whether the infection be of cutaneous, sinonasal, pulmonary existing focus of infection perhaps in relation to his parti- or CNS origin. Several factors in this case led us to perform cularly poor living style. Infections caused by Absidia cor- surgery on this BMT recipient. First, every 2 days, chest ymbifera are exceedingly rare.3 Less than 1% of cases have CT scan showed stable but non-regressive disease after 10 been described to date, and those reported never mention days treatment with i.v. liposomal amphotericin B, resulting the occurrence of this fungus isolated in the lung where in a persistent high risk of subsequent hemoptysis and sud- the most frequent mucor is Rhizopus arrhizus. One study3 den death. Next, the patient had rejected the donor marrow showed that localized sinonasal disease or CNS disease is despite growth factors, and, as a result, had delayed recov- more common in BMT recipients as a consequence of hem- ery of his own neutrophil count. This further increased the atogenous dissemination from the lung because of the rap- risk of dissemination. There was, finally, moderate renal idly progressive nature of this infection. Inhalation of failure due to cyclosporin, aminoside, vancomicin and lipo- spores with subsequent hematogenous dissemination is somal amphotericin B, all known for their cumulative thought to occur in immunocompromised hosts. However, renal toxicity. none of our other patients suffered from mucormycoses in The case reported here serves to emphasize that poor the past. From an epidemiological point of view, the inci- social standards can be a risk factor and we questioned the dence of mucormycoses in such immunocompromised place of systemic antifungal prophylactic treatment with patients is lower than that caused by other phyllophane i.v. liposomal amphotericin B.10,11 Despite a high level of fungi such as Aspergillus spp. This incidence may be suspicion, quick diagnosis, early treatment with systemic explained by the ecology of this fungi and differences antifungals, growth factors and local surgical control of the between the relative abundance of fungal spores in indoor infection, the mortality rate is still high. This patient died air. Numerous studies on microbial evaluation of indoor from respiratory failure in the context of multi-organ fail- environments have shown that the most frequently isolated ure, acute hepatic GVHD, and drug-induced kidney failure. fungi were: Penicillium spp., Cladosporium spp., Aspergil- The Mucor appeared to have been cleared because none lus spp.; however, Mucor species were rarely isolated.4 In was isolated from the second BAL. Thus, the presence of our case, air sampling performed with an Andersen appar- Candida glabrata was probably an invasive reinfection atus (Andersen 2000, Atlanta, GA, USA) was carried out because no other organism was found to explain the exten- in both the ward and the patient’s room and did not reveal sive pneumonitis. However, the Candida glabrata seen on the presence of this fungus. As in most cases described,3 the second BAL remained although sensitive in vitro to it was particularly hard to initially diagnose this infection, amphotericin B given in adequate doses and never stopped. and recognition of these rare infections requires a high index of suspicion: the infection usually develops within the first 100 days post-BMT.2 Patients are predisposed indi- Acknowledgements viduals with some of the main risk factors.2 However, our patient was not diabetic, had never received steroids or We thank Nadine Franc¸ois, and Gabriel Reboux for their expert been aplastic, having only been treated with interferon and technical assistance. We also thank Wendy Folligett, Dr Tre- hydroxyurea. Clinical signs which should alert physicians leaven, and Dr Kerr for their help with the English grammatical include unremitting fever despite broad-spectrum antibac- corrections. terial treatment and progression of lung infiltrates regard- less of the radiological presentation. However, none of these characteristics are specific. References From a mycological point of view, when Mucor species have been isolated from aspirated material, the results 1 De Bock R. Epidemiology of invasive fungal infections in bone marrow transplantation. Bone Marrow Transplant 1994; should be interpreted with caution because these species are 14 (Suppl. 5): S1-S2. also common contaminants in the mycological laboratory. 2 Gaziev D, Baronciani D, Galimberti M et al. Mucormycosis Therefore, the demonstration of broad coenocytic hyphae after bone marrow transplantation: report of four cases in thal- in histological samples is considered more significant than assemia and review of the literature. Bone Marrow Transplant isolation after culture. 1996; 17: 409–414. Anti-fungal therapy and surgical resection for zygomycosis X Leleu et al 420 3 Morrison VA, McGlave PB. Mucormycosis in the BMT popu- 8 Trigg ME, Menezes AH, Giller R et al. Combined anti-fungal lation. 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