We report the first case of infection caused by Graphium basitruncatum in a man with acute leukemia who developed persistent fungemia and skin lesions. G. basitruncatum, a member of the Microascaceae, is phylogenetically and morphologically distinct from Graphium penicillioides and the opportunistic pathogens Scedosporium apiospermum (Pseudallescheria boydii) and Scedosporium prolificans.
CASE REPORTA 70-year-old man, previously in good health, was diagnosed with acute myelogenous leukemia, FAB M0, in November 2005. The patient was originally from Germany and had immigrated to Canada in 1983. He was admitted to the hospital and received induction chemotherapy with daunorubicin from days 1 to 3 and cytarabine from days 1 to 7. He was also given itraconazole, 200-mg oral solution, twice daily as antifungal prophylaxis for 4 weeks starting on day 4 of chemotherapy. The postinduction course was complicated by the development of fever and neutropenia (absolute neutrophil count, 辖500 cells/ l), for which he received piperacillin-tazobactam and ciprofloxacin intravenously. This resulted in resolution of fever after 1 week. Investigations, including blood cultures, urine cultures, and computed tomography of the chest, did not reveal a source of infection. He failed to have adequate neutrophil recovery after the first course of induction chemotherapy and was discharged from the hospital on no antimicrobials, with an absolute neutrophil count of 0 cells/l.Three weeks later, the patient was rehospitalized with febrile neutropenia. His physical examination was remarkable for several nontender, erythematous skin nodules, primarily along his extremities (Fig. 1). Blood cultures were done in broth bottles and kept in a continuous monitoring system (BacT/ALERT; BioM茅rieux Inc., Durham, NC). He was started on broadspectrum antimicrobial therapy consisting of piperacillintazobactam, ciprofloxacin, and vancomycin. Two blood cultures from the central venous catheter taken 4 days apart were positive and showed the presence of fungal hyphae. He was then started on a combination of intravenous voriconazole, 4 mg/kg of body weight twice daily, and caspofungin, 50 mg daily. He continued to be febrile but subsequently had three negative blood cultures. Computed tomography of his chest was normal. After 10 days of antifungal therapy, he received repeat induction chemotherapy with mitoxantrone and etoposide on days 1 to 5, followed by high-dose cytarabine on days 6 and 7. Despite ongoing combination antifungal therapy with voriconazole and caspofungin, the patient's fungemia recurred, and seven subsequent blood cultures over a 1-month period remained positive for a grayish fungus that was later identified as Graphium basitruncatum. The patient's central venous catheter was removed. A transesophageal echocardiogram showed no vegetations. Intravenous liposomal amphotericin B, 5 mg/kg daily, was started, and this resulted in defervesence, regression of skin lesions, and no evidence of ongoing fungemia. The patient subsequently recovered his n...