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Fungal infections and tumour lysis syndrome: case report A 68-year-old woman developed pulmonary aspergillosis and Fusarium spp infection during treatment with ibrutinib for chronic lymphocytic leukaemia (CLL). Additionally, she developed fatal tumour lysis syndrome during treatment with venetoclax for CLL [routes not stated; not all dosages and time to reactions onset stated]. The woman was diagnosed with CLL in 1997 at the age of 68 years. She received multiple lines of therapy comprising fludarabine, cyclophosphamide, rituximab, bevacizumab, vincristine, doxorubicin, dexamethasone, methotrexate, cytarabine, ofatumumab, methylprednisolone and oxaliplatin. She also received ibrutinib 840 mg/day as part of clinical trial. Approximately one year following the discontinuation of ibrutinib, she developed probable invasive pulmonary aspergillosis. Aspergillus niger grew in sputum culture. The woman received treatment with voriconazole. However after 8 weeks, a repeat chest CT scan revealed a persistent left lower lobe infiltrate. Voriconazole was changed to posaconazole with slow response. After six months, a repeat CT scan showed complete resolution of pneumonia. Posaconazole was discontinued. Continuous mould-active therapy was recommended as secondary prophylaxis for six months during subsequent immunosuppressive leukaemia treatment. Approximately after one year, she started receiving monotherapy with ibrutinib 280 mg/day for progressive CLL. After approximately four years of ibrutinib treatment, she underwent sinus surgery at another healthcare facility due to recent recurrent sinopulmonary infections. Cultures from debridement reported growth of Fusarium spp. However, she did receive immune globulin replacement for history of low serum IgG levels. After the surgery, systemic antifungal treatment was not started for unknown reasons. She did not follow-up until two months after the surgery. Later, she was admitted for rapidly progressive CLL. Ibrutinib was changed to venetoclax. Five days following the initiation of venetoclax, she developed fever. Head and neck evaluation revealed crusting at the middle turbinates. A CT scan demonstrated sinusitis. Amphotericin-B-liposomal was started as antifungal treatment. While on venetoclax, she developed severe tumour lysis syndrome, which resulted into acute kidney injury, fluid overload, acidosis, sepsis and acute respiratory failure. She needed intubation. Despite the treatment with amphotericin-B-liposomal for 2 weeks, she developed refractory multi-organ failure and cardiac arrest. Two months after the diagnosis of non-Aspergillus invasive mould infections, she died due to complications of venetoclax-induced tumour lysis syndrome. Autopsy was not performed. Anastasopoulou A, et al. Non-Aspergillus invasive mould infections in patients treated with ibrutinib. Mycoses 63: 787-793, No. 8, Aug 2020. Available from: URL: http:// 803514795 doi.org/10.1111/myc.13120

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