Infect Chemother.  2012 Feb;44(1):26-30. 10.3947/ic.2012.44.1.26.

Successful Treatment of Pneumonia caused by Aspergillus terrerus and Cytomegalovirus after Chemotherapy for Acute Myelogenous Leukemia

• Lee MY
• Kim SH
• Kwon JC
• Lee DG
• Cho SG
• Cho SY
• Hwang YM
• Song MA

• KMID: 1782395
• DOI: http://doi.org/10.3947/ic.2012.44.1.26

Abstract

We report a case of pneumonia caused by Aspergillus terreus and cytomegalovirus (CMV) in a patient with acute myleogenous leukemia (AML) after remission induction chemotherapy. A 19-year-old woman underwent chemotherapy for AML. Twenty-three days after completing chemotherapy, she experienced a neutropenic fever with a rapidly-progressive pulmonary infiltration. In those days, her serum galactomannan immunoassay was 4.7 and she was treated with intravenous voriconazole (6 mg/kg q12h for 2 doses, followed by 4 mg/kg q12h) because of persistent fever and radiological worsening, despite the administration of amphotericin B deoxycholate (1 mg/kg q24h) for 7 days. A chest CT showed wedge-shaped consolidation with a central hypodense lesion and an air-crescent sign in the right middle lobe. With maintenance therapy of oral voriconazole for 10 weeks, a partial response was shown and neutrophil count was still less than 100/mm3. A lobectomy of the right middle lobe was performed. A. terreus was discovered from the lung tissue. At the same time, giant cells with intranuclear inclusions were found and immunohistochemical staining for CMV was positive. Ganciclovir (5 mg/kg q12h) was added to voriconazole therapy for 3 weeks after surgery, and then cord blood hematopoietic stem cell transplantation (HSCT) was performed. During HSCT, foscarnet (60 mg/kg q12h) was substituted for ganciclovir, and both antiviral agents were used alternatively due to CMV DNAemia. After 83 days from HSCT, the patient achieved successful engraftment and discharged without worsening the pneumonia.

Keyword

Aspergillus terreus; Cytomegalovirus; Pneumonia; Leukemia; Myeloid; Acute

MeSH Terms

Amphotericin B
Antiviral Agents
Aspergillus
Cytomegalovirus
Deoxycholic Acid
Drug Combinations
Female
Fetal Blood
Fever
Foscarnet
Ganciclovir
Giant Cells
Hematopoietic Stem Cell Transplantation
Humans
Immunoassay
Intranuclear Inclusion Bodies
Leukemia
Leukemia, Myeloid, Acute
Lung
Mannans
Neutrophils
Pneumonia
Pyrimidines
Remission Induction
Thorax
Triazoles
Young Adult
Amphotericin B
Antiviral Agents
Deoxycholic Acid
Drug Combinations
Foscarnet
Ganciclovir
Mannans
Pyrimidines
Triazoles

Figure

• 

  Figure 1 (A) Chest CT shows a wedge-shaped consolidation with focal necrosis and a central cavitary lesion on the right middle lobe. (B) On a follow-up chest CT after 10 weeks of voriconazole therapy, consolidation still remains with a focal necrosis and central cavitary lesion in the right middle lobe.

• 

  Figure 2 On hematoxylin-eosin staining, lung tissue from the cavitary lesion shows central hemorrhagic necrosis with infiltration of acute inflammatory cells (insertion: filamentous, branching septated hyphae within the necrotic tissue, Periodic Acid Schiff stain, ×400).

• 

  Figure 3 Lung specimen from the area of the cavitary lesion shows giant cells with intranuclear inclusions and a perinuclear halo (arrow, hematoxylin-eosin stain, ×400) (insertion: on immunohistochemistry lung biopsy specimen from the cavitary lesion shows CMV-virus-positive cells stained brown).

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