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Busulfan/fludarabine/voriconazole Invasive fusariosis and lack of efficacy: case report

A 13-year-old girl developed invasive fusariosis caused by Fusarium oxysporum following conditioning therapy with busulfan and fludarabine for acute myeloid leukaemia (AML). Additionally, she exhibited lack of effecacy during treatment with voriconazole for invasive fusariosis [not all routes and dosages stated]. The girl, who AML, presented with relapse of AML, and was scheduled to undergo allogeneic bone marrow transplant (BMT). She received myelosuppressive conditioning therapy with busulfan and fludarabine along with concomitant infectious prophylaxis with aciclovir [Acyclovir], cotrimoxazole [trimethoprim/sulfamethoxazole] and fluconazole. Five days following the transplant, she received filgrastim [Neupogen]. After one week of the BMT, she started to experience vomiting, headache, central facial paralysis and progressive deterioration of consciousness. The Glasgow scale score was 7. She required admission to the ICU. Her antimicrobials were changed to vancomycin and meropenem. At that time, sudden appearance of multiple disseminated skin lesions were noted and a dermatologist was consulted. Physical examination revealed disseminated dermatosis on the lower and upper limbs and trunk characterised by round erythematous-violaceous macules, infiltrated on blisters and palpation with haemorrhagic content inside. Based on further investigations including blood culture, a diagnosis of invasive fusariosis due to Fusarium oxysporum was made. The girl received treatment with IV voriconazole 4 mg/kg/dose twice daily. She evolved unfavourably and the skin lesions had a central necrotic appearance with a scaling collarette (voriconazole lack of efficacy). She developed severe diabetes insipidus with hypernatraemia crisis. Brain MRI 20 days post-transplant showed cerebral oedema and extensive ischaemic lesions with tonsillar herniation and bulbospinal compression. Three weeks following the transplant, she died due to invasive fusariosis. Turra N, et al. Multisystemic fusariosis with fulminant evolution. Anais Brasileiros de Dermatologia 95: 645-648, No. 5, Sep-Oct 2020. Available from: URL: http:// doi.org/10.1016/j.abd.2020.03.007

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Reactions 5 Dec 2020 No. 1833