Scedosporium apiospermum SINUSITIS AFTER BONE MARROW TRANSPLANTATION: REPORT OF A CASE

Abstract

A forty-year-old man underwent an allogeneic BMT from his HLA identical sister. GvHD prophylaxis was done with cyclosporine (CyA), methotrexate and prednisone (PDN). On day +90 extensive GvHD was noted and higher doses of immunosuppressive drugs alternating CyA with PDN were initiated. Patient's follow-up was complicated by intermittent episodes of leukopenia and monthly episodes of sinusitis or pneumonia. One year after BMT, the patient developed hoarseness and nasal voice. No etiologic agent could be identified on a biopsy sample of the vocal chord. Upon tapering the doses of immunosuppressive drugs, the patient had worsening of chronic GvHD and was reintroduced on high doses of cyclosporine alternating with prednisone on day +550. Three months later, GvHD remained out of control and the patient was started on azathioprine. On day +700, hoarseness and nasal voice recurred. Another biopsy of the left vocal chord failed to demonstrate infection. Episodes of sinusitis became more frequent and azathioprine was withheld 3 months after it was started. One month later, the patient had bloody nasal discharge and surgical drainage of maxillary sinuses was performed. Histopathology showed hyphae and cultures grew Scedosporium apiospermum. ltraconazole 800 mg/day was initiated. The patient developed progressive respiratory failure and died 15 days later.<br>Paciente portador de leucemia mielóide crônica, com irmã HLA-compatível foi submetido a transplante alogênico de medula óssea. No dia +90 pós-TMO foi diagnosticado doença do enxerto contra o hospedeiro (DECH) extensa e iniciado protocolo alternado de imunossupressão com altas doses de ciclosporina A e prednisona. O seguimento ambulatorial foi complicado, com granulocitopenia intermitente e quadros frequentes de sinusite e pneumonia. Um ano após o transplante, o paciente apresentou rouquidão e voz anasalada. Foi realizada uma biópsia de corda vocal mas nenhum agente infeccioso pode ser identificado. Na diminuição das doses das drogas imunossupressoras, houve piora da DECH crônica e foi reiniciado esquema de doses altas no dia +550. Três meses após, permanecendo o quadro de DECH fora do controle, foi tentado imunossupressão com azatioprina sem sucesso. Novo episódio de rouquidão foi observado no dia +700, mas nenhum agente pode ser identificado em nova biópsia de corda vocal. Após um mês, o paciente apresentou secreção nasal sanguinolenta e foi realizada uma raspagem cirúrgica dos seios maxilares. Scedosporium apiospermum foi identificado nas culturas iniciando-se itraconazol na dose de 800 mg/dia. O paciente desenvolveu falência respiratória progressiva e foi a óbito em 15 dias

Scedosporium/Pseudallescheria Infections

“…Fungus balls in the paranasal sinuses and invasive maxillary sinusitis due to S. apiospermum and S. prolificans (which was of probable dental origin) have been described in immunocompromised patients. [34][35][36][37] Invasive fungal sinusitis with extension to mastoiditis has also been reported in a patient with acquired immunodeficiency syndrome (AIDS). 38 Scedosporium apiospermum is a common mold colonizing the respiratory tract of people with cystic fibrosis.…”

Scedosporium apiospermum as a rare cause of fungal rhinosinusitis

“…Till date five cases of rhinosinusitis caused by Scedosporium species are reported in English literature[Table 1]. [45678] In present case, the patient is a known diabetic on oral hypoglycemic drugs with adequate blood sugar control who is doing well on 6 months follow up.…”

Histopathological clues in the diagnosis of fungal infection by Scedosporium in a case of endophthalmitis starting as conjunctivitis

“…The final result is persistent arthritis, keratitis, osteomyelitis or subcutaneous infections . The last condition is usually seen in immunosuppressed patients, in whom the clinical presentation can be more complicated through the development of invasive sinusitis, pneumonia, arthritis with osteomyelitis, cutaneous and subcutaneous granulomata or disseminated systemic disease, with a tendency to disseminate to the central nervous system with meningitis or brain abscesses . Most cases of endophthalmitis by Scedosporium have been described in the context of immunosuppression .…”

“…The main differential diagnosis of S. apiospermum is Aspergillus, and many reports have claimed that both genders cannot be distinguished from each other in the histopathological sections. 1 In their morphological descriptions, some authors have mentioned that 'Scedosporium apiospermum is morphologically identical to Aspergillus and Fusarium spp. in addition to several other organisms: All of them made of [sic]septate hyphae that branch dichotomously at 45-degree angles.'…”