A case of cutaneous penicilliosis in a child with acute myeloid leukaemia

Abstract

Introduction: We present a case of cutaneous penicilliosis in a paediatric patient with acute myeloid leukaemia (AML). Case report: A 2-year-old boy with AML first developed probable pulmonary aspergillosis during induction chemotherapy in an overseas centre in May 2013, and was treated with AmBisome and voriconazole. When he was admitted to our centre with relapsed AML in October 2013, he was given a fifth course of chemotherapy, and treated with AmBisome for probable pulmonary aspergillosis in view of pulmonary nodular opacities on computed tomography. He thereafter developed an erythematous skin lesion with central eschar on his right hand and left calf. Serum and bronchoalveolar lavage galactomannan antigen (GM Ag) indices increased to a value of >10. AmBisome was changed to voriconazole, and caspofungin was added for 10 days. The left calf skin biopsy showed abundant fungal hyphae with septations. A skin culture grew Penicillium citrinum with MICs (μg ml− 1) of: caspofungin 0.016, itraconazole 0.5, amphotericin 1.5 and voriconazole >256.Caspofungin and itraconazole were commenced, and voriconazole was discontinued. The skin lesions and serial GM Ag indices improved. The patient later developed increasing GM Ag indices to a value of >10, which was attributed to Aspergillus flavus left pulmonary mycetoma, which was surgically resected. He eventually succumbed to relapsed AML after a bone-marrow transplant. Conclusion: To the best of our knowledge, this is the first paediatric case of P. citrinum infection. Rising GM Ag indices were attributed to cross-reactivity of Penicillium spp. with GM Ag enzyme immunoassays.

A case report of fungal infection associated acute fibrinous and organizing pneumonitis

“…We considered P. citrinum infection in our patient for the following reasons: (i) The growth of P. citrinum in five separate sputum cultures from a symptomatic patient with uncontrolled DM prompted careful consideration of a P. citrinum pneumonia; (ii) Pathological biopsy revealed small abscesses and granulomatous nodules, and special stain (PAM) result was positive, suggesting fungal pneumonia; (iii) There was no evidence to confirm infection of other organisms. GM test in BAL fluid was negative which is in contrast with previous reports [15,16]. It's likely that our patient was nonagranulocytosis and received voriconazole, to which false-negative GM test results have been attributed.…”

“…Voriconazole should not be considered first-line for the empiric treatment of P. citrinum [16]. The high MIC of P. citrinum isolate in our patient, which is consistent with previous reports [15,16,22], may partly explain why the initial administration of voriconazole was ineffective. Therefore, early antifungal susceptibility testing is essential for appropriate treatment to improve clinical outcomes.…”

Penicillium citrinum : Opportunistic pathogen or idle bystander? A case analysis with demonstration of galactomannan cross-reactivity

“…Only one of the 4 published case reports of P. citrinum infections reported a voriconazole MIC. That MIC was also above the limits of quantification, albeit at > 256 μg ml −1 [8]. The only other report of P. citrinum sensitivities encountered after a broad literature search was authored by a group at the Fungal Testing Laboratory at the University of Texas Health Science Center [11].…”

“…We performed an extensive literature search identifying a total of four reports of P. citrinum infection in humans, three of which occurred in patients with acute leukemia receiving intensive chemotherapy [6] , [7] , [8] and one which occurred in the setting of direct inoculation into an immune-privileged space [9] . Based on our patient's significantly milder degree of immunocompromise relative to that induced by acute leukemia plus chemotherapy, we concluded that P. citrinum was unlikely to have been a tissue-invasive cause of pneumonia in her case.…”

Identification and Antifungal Susceptibility of Penicillium-Like Fungi from Clinical Samples in the United States

“…P. citrinum has been reported to be a human-opportunistic pathogen responsible for keratitis, cutaneous infections, and pneumonia (25)(26)(27)(28).…”