micafungin and Leukemia--Myelogenous--Chronic--BCR-ABL-Positive

Non-Candida opportunistic yeasts are emerging causes of bloodstream infection (BSI) in immunocompromised hosts. However, their clinical presentation, management, and outcomes in stem cell transplant (SCT) recipients are not well described. We report the first case to our knowledge of Pseudozyma BSI in a SCT recipient. He had evidence of cutaneous involvement, which has not been previously described in the literature. He became infected while neutropenic and receiving empiric micafungin, which is notable because Pseudozyma is reported to be resistant to echinocandins. He was successfully treated with the sequential use of liposomal amphotericin B and voriconazole. A review of the literature revealed nine reported instances of Pseudozyma fungemia. We performed a retrospective review of 3557 SCT recipients at our institution from January 2000 to June 2015 and identified four additional cases of non-Candida yeast BSIs. These include two with Cryptococcus, one with Trichosporon, and one with Saccharomyces. Pseudozyma and other non-Candida yeasts are emerging pathogens that can cause severe and disseminated infections in SCT recipients and other immunocompromised hosts. Clinicians should have a high degree of suspicion for echinocandin-resistant yeasts, if patients develop breakthrough yeast BSIs while receiving echinocandin therapy.

Topics: Adult; Amphotericin B; Antifungal Agents; Antineoplastic Combined Chemotherapy Protocols; Biopsy; Cryptococcus; Cytarabine; Dermatomycoses; Echinocandins; Exanthema; Fever; Fungemia; Granulocyte Colony-Stimulating Factor; Hematopoietic Stem Cell Transplantation; Humans; Idarubicin; Immunocompromised Host; Leukemia, Myelogenous, Chronic, BCR-ABL Positive; Lipopeptides; Male; Micafungin; Opportunistic Infections; Retrospective Studies; Saccharomyces; Salvage Therapy; Trichosporon; Ustilaginales; Vidarabine; Voriconazole; Yeasts

A 35-year-old man developed invasive pulmonary aspergillosis (IPA) with severe neutropenia after umbilical cord stem cell transplantation for chronic myelogenous leukemia. Filamentous fungus isolated from his sputum was identified as Aspergillus terreus. Despite systemic amphotericin B (AMPH) administration, IPA progressed. However, intravenous administration of micafungin (MCFG) and oral itraconazole improved clinical data and symptoms, although he later died of massive hemoptysis. Examination of the in vitro susceptibility of this A. terreus isolate to MCFG revealed a good minimum inhibitory concentration and good time-kill assay results compared to AMPH. Thus, MCFG might be useful for IPA caused by A. terreus.

Topics: Adult; Antifungal Agents; Aspergillosis; Aspergillus; Drug Therapy, Combination; Echinocandins; Humans; Itraconazole; Leukemia, Myelogenous, Chronic, BCR-ABL Positive; Lipopeptides; Lipoproteins; Lung Diseases, Fungal; Male; Micafungin; Neutropenia; Opportunistic Infections; Peptides, Cyclic; Sputum; Stem Cell Transplantation