Summary:develop invasive fungal infections. [1][2][3][4] The diagnosis of fungal infections is particularly difficult in immunocompromised patients, and most patients are treated presumptively. Sixty-four adult patients (median age 43) with hematologic malignancies who were immunocompromised after Early institution of anti-fungal therapy is associated with better outcome, and withholding therapy until a definitive allogeneic (n = 23) or autologous (n = 9) blood/marrow transplantation, or chemotherapy (n = 32) received 68 diagnosis is made results in dissemination of the infection with a high mortality. 4 courses of amphotericin B lipid complex (ABLC, Abelcet) at the daily dose of 5 mg/kg for presumed Amphotericin B is the primary treatment for systemic fungal infections in immunocompromised patients because (n = 52) or proven (n = 16) fungal infection. The major indications for ABLC were failure of previous antifunof its broad spectrum of activity. 5,6 However, its use is limited by a variety of adverse effects including severe gal therapy and/or renal dysfunction. Fifty-three treatment courses in 49 patients comprising 4-58 doses systemic reactions such as fever, rigors, phlebitis and bronchospasm. 6 The major problem with amphotericin is (median 10) were considered evaluable. Fourteen courses administered for confirmed infections resulted its dose-related nephrotoxicity which compromises its efficacy in treating systemic fungal infections and restricts its in nine complete and one partial responses, and four failures (71% response). Thirty-nine empiric courses prophylactic use. 7 Drug-induced renal dysfunction is a major concern after blood or marrow transplantation resulted in 18 complete and six partial responses, and 14 failures (64% response). The overall response rate (BMT), 8,9 where the use of a less nephrotoxic formulation of amphotericin would be particularly attractive. 10 was 66%. Five of seven evaluable patients with aspergillus pneumonia responded. Response rates were compa-A number of lipid-based formulations of amphotericin have been developed to improve the tissue distribution of rable for chemotherapy, autograft and allograft recipients. The change in serum creatinine from the beginning amphotericin and to reduce the toxicity associated with conventional amphotericin. 10 Amphotericin B lipid comto the end of therapy was −284 to +277 mol/l (median +24). The creatinine doubled during seven evaluable plex (ABLC) is derived from a liposomal formulation of amphotericin B consisting of dimyristoyl-phosphatidylcourses of therapy, five of which were associated with concomitant nephrotoxic therapy. Nephrotoxicity was choline and dimyristoyl-phosphatidylglycerol in a 7:3 molar ratio. Unlike the original liposomal formulation, comparable for transplant and chemotherapy patients. Renal dysfunction necessitated discontinuation of ABLC has a ribbon-like appearance. 10 Here, we report our experience with the use of ABLC ABLC in only four patients. These data suggest that ABLC is effective in presumed or co...
Empirical antifungal therapy is frequently used in allogeneic transplant patients who have persistent febrile neutropenia and can be associated with high cost, toxicity and breakthrough infections. There are limited reports of strategies for early diagnosis of invasive fungal infection (IFI) and, to our knowledge, no reports of treatment strategies based only on high-resolution computerized tomography (HRCT) scans. We used an early treatment strategy for IFI in 99 consecutive patients undergoing allogeneic transplantation. Patients received caspofungin if they had antibiotic-resistant neutropenic fever for more than 72 h and a positive HRCT scan. Fifty-three of 99 patients (54%) had antibiotic-resistant neutropenic fever at 72 h and would have received parenteral antifungal treatment if an empirical approach had been used. The HRCT-based strategy reduced the use of parenteral antifungal agents to 17/99 patients (17%), a 68% reduction. No subsequent diagnoses of IFI occurred within 100 days in patients with a negative HRCT. Only one patient died from IFI within 100 days. These data suggest that this non-empirical strategy may be feasible and that caspofungin may be effective in this setting. A randomized controlled trial is warranted to further assess these results.
trephine specimens from positive bone marrow showed granulomata and nine showed acid-fast bacilli. No acid-fast bacilli were seen in the absence of granulomata.
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