Role of Antifungal Prophylaxis in Invasive Fungal Infection in Children with Acute Lymphoblastic Leukemia—A Retrospective Cross-Sectional Study

Abstract

Introduction Acute lymphoblastic leukemia (ALL) is the most common childhood cancer. Its outcome in India is not as good as that in the western world. One of the important reasons for lesser survival rates is opportunistic infections, including invasive fungal infections (IFIs). Antifungal prophylaxis (AFP) in ALL children is routinely not followed. However, owing to its incidence in high-risk ALL, this study is focused on the use of AFP in those children. Objectives This retrospective study investigated the role of AFP in newly diagnosed children with high-risk ALL on intensive blocks of therapy on regimens B and C of the United Kingdom Acute Lymphoblastic Leukemia 2003 protocol. Materials and Methods The study was conducted in a tertiary care center from 1st December 2013 to 31st December 2019 and included children with ALL from 1 to 18 years of age. Routine AFP with voriconazole was commenced for high-risk ALL children from 1st July 2017 onward in our center. We analyzed data of all IFIs in children before and after AFP with National Cancer Institute high-risk status who had been started on regimen B induction and regimen B or C consolidation and intensification phases. Results A total of 55 children with high-risk ALL were included in the study. The median age was 4 years, with the majority being between the age of 1 and 10 years (38 out of 55; 65%) and predominantly male (36 out of 55; 69%). Total incidence of IFI in our cohort was 51% (28 out of 55). A significant number of children (16 out of 22 [70%]) who were not on prophylaxis developed IFI versus children (12 out of 33 [28%]) on prophylaxis (p = 0.008). The most common organisms isolated were Candida parapsilosis and Candida tropicalis. Children not receiving AFP were found to be 4.7 times (95% confidence interval: 1.44–15.13) more likely to get IFI than the ones receiving AFP. The presence of concurrent bacterial infection increases the risk of IFI (p = 0.04). Conclusion The incidence of IFI was high in high-risk ALL children who were not on AFP. The introduction of routine AFP reduced the incidence of IFI.

Subcutaneous Microabscesses and Myositis as Part of Immune Reconstitution Inflammatory Syndrome due to Chronic Disseminated Candidiasis in a Child With Acute Lymphoblastic Leukemia

“…As reported by Zając-Spychała et al10 and Shkalim-Zemer and colleagues, patients developed CDC despite the antifungal prophylaxis 10,12. Our patient was not started on antifungal prophylaxis since she was on a standard risk 3-drug regimen, which is the usual practice 16…”

“…10,12 Our patient was not started on antifungal prophylaxis since she was on a standard risk 3-drug regimen, which is the usual practice. 16 To summarize, IRIS is known to complicate the clinical course of ALL in children, especially with a chronic candida infection. Our patient had an unusual presentation with subcutaneous microabscesses and severe myositis.…”