Recurrent Disseminated Skin Lesions Due to Metarrhizium anisopliae in an Adult Patient with Acute Myelogenous Leukemia

Abstract

Metarrhizium anisopliae is a common insect pathogen that rarely causes infection in animals and humans. We report the first case of a disseminated skin infection in an immunocompromised adult patient. To date, only five cases of the disease in humans have been reported. There is no standard treatment for this infection. CASE REPORTA 62-year-old male presented in April 2005 with fever and malaise. Blood counts revealed pancytopenia with 330 neutrophils/l and 65% blasts. A bone marrow aspirate established a diagnosis of acute myelogenous leukemia (M2) with a normal cytogenetic study. He received induction chemotherapy with idarrubicine (12 mg/m 2 ϫ 3 days) and cytarabine (200 mg/m 2 ϫ 7 days). The first day of chemotherapy was designated day 0. Because of the persistence of blasts in the bone marrow, further treatment with mitoxantrone (10 mg/m 2 ϫ 3 days) and cytarabine (400 mg/m 2 ϫ 5 days) was given. Prophylactic fluconazole was administered from day ϩ3 after induction chemotherapy until day ϩ39. A brief episode of fever of unknown origin developed between days ϩ3 and ϩ7 and was treated empirically with imipenem. On day ϩ42 after induction chemotherapy, maculopapular skin lesions appeared, disseminating in 48 h and involving the face, trunk, and limbs (up to 42 papules with central ulceration were counted). Some of the lesions resembled ecthyma gangrenosum. A skin biopsy sample showed dermoepidermic necrolysis and fibrin thrombi. No cultures were obtained at the time. The clinical picture was considered to be compatible with a septic process, although a toxic epidermal necrolysis was also possible. When the skin lesions appeared, the patient was neutropenic and was receiving empirical antimicrobial therapy with imipenem and teicoplanin. From day ϩ39 after induction chemotherapy, the patient was started on caspofungin because of a relapsing neutropenic fever. Four days later, he became afebrile and his neutrophil count increased to more than 500/l. Caspofungin and antibiotics were withheld, and the patient was discharged on day ϩ50 after induction chemotherapy without any antifungal drug. The skin lesions gradually improved.Two more consolidation chemotherapy cycles were administered in June and August 2005 (23 mg idarrubicine ϫ 2 days and 390 mg cytarabine ϫ 5 days in both cycles). No fever or skin lesions appeared, and no antifungal therapy was administered during the first consolidation chemotherapy. Two new skin lesions identical to the previous ones appeared on day ϩ10 after the second consolidation cycle, before he became neutropenic on day ϩ12. Because of the appearance of these lesions, fluconazole was started on day ϩ10 and maintained until day ϩ28 after consolidation chemotherapy, when the patient was discharged. The lesions gradually disappeared.In September and October 2005, the patient's leukemia was in complete remission and his peripheral blood counts were normal. During this period of time, while the patient was waiting for autologous stem cell transplantation (SCT), a new flare-up of disseminate...

Performance of Panfungal- and Specific-PCR-Based Procedures for Etiological Diagnosis of Invasive Fungal Diseases on Tissue Biopsy Specimens with Proven Infection: a 7-Year Retrospective Analysis from a Reference Laboratory

“…The most frequently observed species in this group belonged to the genera Scedosporium and Fusarium. Also present were species that were rarely described previously as causing infectious diseases, such as Phomopsis longicolla, Metarhizium anisopliae (12), Arthrographis kalrae (13), and Bipolaris spicifera. Four cases of mixed infections were detected; two of those cases involved pediatric oncological patients from the same hospital (14), and the other cases involved an oncohematological patient and a subject addicted to alcohol.…”

Photodynamic Antifungal Chemotherapy†

“…Metarhizium anisopliae is a worldwide entomopathogenic deuteromycete that has been used for decades in programs of agricultural pest and disease‐vector control in various countries. Although M. anisopliae is not considered to be pathogenic for humans or domestic animals, starting in the late 1990s some rare cases of mycoses caused by the fungus in both immunocompromised and immunocompetent individuals have been reported (25). Gonzales and colleagues (26) compared the conidial photosensitization of two fungal species ( M. anisopliae and Aspergillus nidulans ) with MB and TBO under different incubation and light conditions.…”

Pediatric Metarrhizium anisopliae keratitis

“…6,8 Two previous single case reports have suggested that topical natamycin is effective against M. anisopliae. 3,4 Systemic antifungals such as voriconazole may be an effective treatment for filamentous keratitis that is not responsive to topical treatment.…”

“…Eight cases of human infection by M. anisopliae have been previously reported, including 3 ocular infections. [3][4][5][6][7][8][9] An 18-year-old Columbian man with a painless round M. anisopliae corneal ulcer was cured with topical natamycin 5% and silver-sulfadiazine 1%. 3 A 36-year-old American female contact lens wearer with mild eye irritation attributable to a 2.5 mm round paracentral M. anisopliae corneal ulcer was left with a stromal scar after a 2-month course of topical medications including natamycin 5% and multiple antibacterials.…”

“…5 Five nonocular cases of M. anisopliae infection have been reported involving the skin and sinuses. [6][7][8][9] Topical natamycin and amphotericin B are polyene antifungals that have been recommended for superficial filamentous fungal keratitis, whereas deeper stromal lesions may require systemic antifungals or keratoplasty. 10 We initially chose amphotericin because it could be compounded immediately by our hospital pharmacist, whereas natamycin was not immediately available from pharmacies in our area.…”