Lethal destructive sinusopathy due to amphotericin B-resistant Aspergillus flavus: A case report.

BACKGROUND: The prevalence of pulmonary aspergillosis and the importance of its early diagnosis are recognized. However, non-pulmonary involvement, including the sinuses region, is not frequently reported, and an infection in this area can affect all paranasal sinuses (pansinusopathy), being a rare pathology that affects immunocompromised hosts. Recent studies have highlighted the occurrence of Aspergillus flavus resistant to antifungal therapy. Therefore, a nasal sinus infection by resistant Aspergillus strains in immunocompromised patients may be linked to a high risk of lethality. CASE REPORT: We are reporting a resistant A. flavus infection in an allogeneic hematopoietic stem cell transplant recipient with episodes of febrile neutropenia, and prolonged use of various antibacterial drugs and antifungal prophylaxis. The patient underwent brain magnetic resonance, which showed the presence of pansinusopathy, and presented necrosis in the left nasal region. Direct microscopic examination of a sample taken from the nasal mucosa revealed the presence of septate hyphae and conidiophores resembling those of A. flavus, that species being the identification achieved with MALDI-TOF MS. Antifungigram was performed by microdilution in broth (EUCAST-E.DEF. 9.3.2) and E-test, and resistance to amphotericin B was shown in both tests. The patient died after septic shock and hemorrhage. CONCLUSIONS: Invasive fungal infections due to amphotericin-B resistant A. flavus may lead to the death of the patient due to an ineffective therapeutic management. Therefore, antifungal susceptibility testing are of utmost importance for administering the proper treatment.

Lethal destructive sinusopathy due to amphotericin B-resistant Aspergillus flavus: A case report

Background:The prevalence of pulmonary aspergillosis and the importance of its early diagnosis are recognized. However, non-pulmonary involvement, including the sinuses region, is not frequently reported, and an infection in this area can affect all paranasal sinuses (pansinusopathy), being a rare pathology that affects immunocompromised hosts. Recent studies have highlighted the occurrence of Aspergillus flavus resistant to antifungal therapy. Therefore, a nasal sinus infection by resistant Aspergillus strains in immunocompromised patients may be linked to a high risk of lethality.Case report:We are reporting a resistant A. flavus infection in an allogeneic hematopoietic stem cell transplant recipient with episodes of febrile neutropenia, and prolonged use of various antibacterial drugs and antifungal prophylaxis. The patient underwent brain magnetic resonance, which showed the presence of pansinusopathy, and presented necrosis in the left nasal region. Direct microscopic examination of a sample taken from the nasal mucosa revealed the presence of septate hyphae and conidiophores resembling those of A. flavus, that species being the identification achieved with MALDI-TOF MS. Antifungigram was performed by microdilution in broth (EUCAST-E.DEF. 9.3.2) and E-test, and resistance to amphotericin B was shown in both tests. The patient died after septic shock and hemorrhage.Conclusions:Invasive fungal infections due to amphotericin-B resistant A. flavus may lead to the death of the patient due to an ineffective therapeutic management. Therefore, antifungal susceptibility testing are of utmost importance for administering the proper treatment. (AU)

Antecedentes:La prevalencia de la aspergilosis pulmonar y la importancia de su diagnóstico precoz son ampliamente conocidos; sin embargo, la afectación extrapulmonar no se informa con frecuencia y son pocos los casos documentados de infección de los senos nasales. Una infección en esta área puede alcanzar todos los senos paranasales (pansinusopatía) cuando afecta a pacientes inmunodeprimidos, lo que agrava la enfermedad preexistente. Estudios recientes han destacado la aparición de cepas que muestran resistencia al tratamiento con fármacos antimicóticos. En el paciente inmunodeprimido una infección de los senos nasales por una cepa de Aspergillus resistente implica un alto riesgo de letalidad.Caso clínico:Presentamos un caso de infección por Aspergillus flavus resistente en un receptor de trasplante alogénico de células madre hematopoyéticas, con episodios de neutropenia febril y uso prolongado de diversos fármacos antibacterianos, además de profilaxis antifúngica. Se realizó una resonancia magnética cerebral que reveló la existencia de pansinusopatía con necrosis en la región nasal izquierda. En el examen microscópico directo de la mucosa nasal se observaron hifas tabicadas y la presencia de conidioforos compatibles con Aspergillus flavus; la identificación con el método MALDI-TOF MS arrojó la especie mencionada. El antifungigrama fue realizado por el método de microdilución en caldo (EUCAST-E.DEF. 9.3.2) y E-test; con ambas técnicas el aislamiento mostró resistencia a la anfotericina B. El paciente falleció tras un shock séptico y hemorragia.Conclusiones:Las infecciones fúngicas invasivas por cepas de Aspergillus flavus resistentes a la anfotericina B puede derivar en la muerte del paciente debido a la ineficacia del tratamiento antifúngico. Es por ello que las pruebas de sensibilidad a los antifúngicos son de suma importancia para establecer así el tratamiento correcto. (AU)

Case Report: Sweet Syndrome in Patients with Sporotrichosis: A 10-Case Series.

Human sporotrichosis is an emerging disease caused by fungi of the genus Sporothrix, distributed worldwide, but mostly in tropical and subtropical regions. This disease is caused by traumatic inoculation of contaminated material (either animal or vegetal in origin) into the skin. Sporotrichosis cases caused by zoonotic transmission through felines have significantly increased over the last 20 years in Brazil. There is a spectrum of clinical outcomes, from classical lymphocutaneous and fixed forms to disseminated manifestations and extracutaneous lesions; however, hypersensitivity reactions related to sporotrichosis, including Sweet syndrome (acute febrile neutrophilic dermatoses), are uncommon. In Brazil, Sporothrix brasiliensis is repeatedly associated with feline infection and has consistently shown higher virulence, tendency to escalate to outbreaks or epidemics, and development of atypical forms. Therefore, the objective of the present study was to report the cases of 10 patients with sporotrichosis infected by S. brasiliensis species who developed Sweet syndrome to alert this association, especially in endemic areas.