A patient with acute promyelocytic leukaemia developed invasive aspergillosis post chemotherapy during a pancytopenic episode, clinically involving the lungs and the gastrointestinal tract. Dichotomously branched septate fungal hyphae were demonstrated microscopically in stools and sputa. Cultures of the samples yielded Aspergillus flavus, which were identical by RFLP and random amplification of polymorphic DNA analyses and antifungal MICs, proving disseminated disease. To the best of the author's knowledge, this is the first time that boluses of fungal hyphae have been demonstrated microscopically in the stools of a patient with gastrointestinal aspergillosis. IntroductionInvasive fungal infections (IFIs) are an important cause of morbidity and mortality in patients with haematological malignancies. Invasive aspergillosis (IA) is particularly common during neutropenic episodes following anticancer chemotherapy (Wright et al., 2003). The most common site of involvement is the respiratory tract. However, autopsy studies conducted in immunocompromised patients with disseminated IA have shown the gastrointestinal tract (GIT) to be a frequent site of sub-clinical involvement (Hori et al., 2002). We describe a patient with acute promyelocytic leukaemia (APML) who developed IA post chemotherapy during a pancytopenic episode. This was diagnosed as disseminated IA by conventional methods of both microscopy and culture. Dissemination was proven in addition by DNA fingerprinting analysis of the Aspergillus flavus isolates from both sputum and stool. The highlight of this case report is the finding of fungal hyphae in the direct microscopic examination of stools, which although unusual, may be a significant finding in an immunocompromised patient. Microbiologists, mycologists and pathologists involved in patient care may thus be able to offer improved support to clinicians by becoming proficient in recognizing and interpreting such forms in clinical samples. Case reportAn 18-year-old male who received consolidation chemotherapy consisting of daunomycin and cytosine arabinoside for acute promyelocytic leukaemia developed febrile neutropenia on the 11th day. Other associated symptoms were throat pain, cough and nasal discharge. Physical examination, however, was normal. His total leukocyte count (TLC) and absolute neutrophil count (ANC) were 300 ml 21 and zero, respectively. Chest X-ray was normal. Sputum culture grew Klebsiella pneumoniae sensitive to aminoglycosides and third-generation cephalosporins. The patient had no indwelling catheter. Despite receiving intravenous ceftazidime, amikacin and fluconazole, along with other supportive measures, fever persisted and his condition worsened with the development of haemoptysis and epistaxis. Hence an aggressive IFI was suspected, for which fluconazole was substituted with amphotericin B at a dose of about 1 mg kg 21 per day (50 mg per day). Two days after a transient improvement in symptoms, the patient's condition deteriorated. He developed diarrhoea and respiratory distress...

Ten confirmed cases of invasive aspergillosis (IA) in cancer patients were analysed retrospectively. Eight were pulmonary, one was sinonasal and one was cutaneous. The majority of patients had haematological malignancies (7), the remaining three were cases of solid tumours. Fever was present in all 10 cases. Cough and lung signs were present in all eight cases of invasive pulmonary aspergillosis. Haemoptysis was encountered in three of nine cases of pulmonary and sinonasal aspergillosis. Mortality was low (2%). While corticosteroids, antibiotics and anticancer chemotherapy/radiotherapy were factors predisposing the patients to IA, neutropenia was perhaps responsible for their mortality. Seven of the patients had other associated pathogens isolated in culture in addition to Aspergillus spp. Aspergillus fumigatus was the predominant species, followed by A. flavus, A. glaucus, A. nidulans and A. niger. Direct microscopic examination (in six of seven cases) and culture (six of seven cases) correlated well with radiographic and clinical findings in cases with lung involvement. Serology for anti-Aspergillus antibodies performed by gel diffusion precipitin test was positive in one case of sinonasal aspergillosis, wherein only one precipitin band was observed. Correlation of clinical symptoms, consistent radiographic findings and microbiological work-up (the latter including a triad of direct microscopy, culture and serology) are required to arrive at a diagnosis of IA, especially where histology cannot form the mainstay of diagnosis.

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