Disseminated Lomentospora prolificans infection in a patient on idelalisib-rituximab therapy for relapsed chronic lympho
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LETTER TO THE EDITOR
Disseminated Lomentospora prolificans infection in a patient on idelalisib-rituximab therapy for relapsed chronic lymphocytic leukaemia Amanda Tey 1
&
Bianca Mohan 1 & Ron Cheah 1 & Claire Dendle 2,3 & Gareth Gregory 3,4
Received: 22 April 2020 / Accepted: 12 May 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020
Dear Editor, Lomentospora prolificans (L. prolificans) is an emerging fungal pathogen that can cause fatal disseminated infection in the immunocompromised [1–4]. L. prolificans is intrinsically multidrug resistant and infections are associated with a high mortality rate, particularly in populations with haematological malignancy [2, 3]. A secondline treatment for chronic lymphocytic leukaemia (CLL) is idelalisib, an oral phosphatidylinositol-3-kinase inhibitor, in combination with rituximab [5]. Idelalisib treatment associates with immune dysfunction requiring Pneumocystis jiroveci pneumonia (PJP) prophylaxis and cytomegalovirus (CMV) monitoring [6–8]. It is possible that idelalisib may predispose patients to other opportunistic pathogens, such as L. prolificans. A 60-year-old female presented with cough, night sweats, and fevers with neutrophils < 0.01 × 10 9/L and CRP 248 mg/L. Her medical history included CLL which had been treated with FCR (fludarabine, cyclophosphamide, and rituximab) 2 years prior. FCR treatment was complicated by possible invasive fungal infection which was treated with 6 weeks of voriconazole. The current presentation occurred after 6 weeks of idelalisib-rituximab therapy for progressive disease. Neutropenia began 10 days prior to admission. The patient’s CMV PCR was negative, and she had not received mould active fungal prophylaxis.
* Amanda Tey [email protected] 1
Pharmacy Department, Monash Health, Clayton, Victoria, Australia
2
Infectious Diseases, Monash Health, Clayton, Victoria, Australia
3
School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia
4
Monash Haematology, Monash Health, Clayton, Victoria, Australia
Idelalisib and rituximab were ceased, and filgrastim and piperacillin-tazobactam were commenced for febrile neutropenia. Valaciclovir was commenced for herpes simplex virus positive oral mucocutaneous disease and viremia, while fluconazole was initiated for swab-proven severe oesophageal candidiasis. Fluconazole was changed to posaconazole following chest computerized tomography (CT) on day 4 (Fig. 1) suggestive of invasive fungal infection. Bronchoscopy was non-contributory. Bone marrow biopsy demonstrated absent granulopoieisis attributed to idelalisib. Voriconazole replaced posaconazole on day 13, upon suspicion of Lomentospora. A voriconazole trough level of 12 mg/L was achieved. When Lomentospora was confirmed on day 14 from the day 9 blood culture, terbinafine was added, and filgrastim was increased. Speciation as L. prolificans was reported on day 16, and sensitivities were reported on day 22, demonstrating likely panresistance with minimum inhibitory concentrations of over 8
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