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Aspergillus appendicitis: case report An 11-year-old boy developed Aspergillus appendicitis following induction therapy with cytarabine, etoposide and mitoxantrone for relapsed acute myeloid leukemia (AML). The boy, who had been monitored for 10 years with a suspected diagnosis of autoimmune lymphoproliferative syndrome due to splenomegaly and skin eruption, was diagnosed with French-American- British M5 AML. He achieved a complete remission following cancer chemotherapy. Subsequently, he received a peripheral blood stem cell transplantation from an HLA matched donor. However, five months after the transplant, AML relapsed. An induction therapy comprising of etoposide, cytarabine and mitoxantrone was started [dosages and routes not stated]. He was also receiving fluconazole for Candida prophylaxis. Fifteen days following the completion of the induction therapy, he presented with fever and abdominal pain. Upon examination, his abdomen was soft without distension. However, tenderness was noted in the right lower quadrant, especially at McBurney’s and Kummell’s points. Complete blood tests revealed a leukocyte count of 0.05×109 /L with 11% neutrophils, a haemoglobin of 8.4 g/dL and a platelet count of 20×109 /L. He was treated with meropenem and teicoplanin without response. His serum CRP levels, b-Dglucan and procalcitonin levels were unremarkable. A contrast-enhanced CT scan showed a swollen appendix with the adjacent tissue inflammation. Subsequently, he was admitted. The boy underwent urgent appendectomy. However, the abdominal pain persisted. Histopathology of the excised appendix lesion exhibited numerous hyphal forms of fungi scattered along the blood vessels and muscle layer. The morphology was characteristic for Aspergillus. No evidence of preceding fungal infection was noted, but the filamentous fungi were identified in the blood vessels of the lesion. Consequently, fluconazole prophylaxis was changed to the therapeutic dose of liposomal amphotericin B. The abdominal pain relieved soon, but neutropenia persisted. Aspergillus galactomannan antigen test was positive and liposomal amphotericin B was changed to voriconazole. Panfungal polymerase chain reaction assay of the excised tissue sample-derived DNA showed >99% sequence identity with Aspergillus niger species complex. The anti-fungal therapy was continued for prolonged period during which, he underwent the second HCT following a successful remission of AML. Yada Y, et al. Acute isolated Aspergillus appendicitis in pediatric leukemia. Journal of Infection and Chemotherapy 26: 1229-1231, No. 11, Nov 2020. Available from: URL: 803501440 http://doi.org/10.1016/j.jiac.2020.07.016

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