Fatal disseminated Trichosporon asahii fungemia in a child with acute lymphoblastic leukemia and a morbilliform eruption

Abstract

Trichosporonosis is a rare, life-threatening, opportunistic fungal infection that affects immunocompromised individuals with neutropenia, particularly those with underlying hematologic malignancies. We present the case of a 10-year-old boy with acute lymphoblastic leukemia who developed a diffuse, morbilliform eruption in the setting of fever and pancytopenia. He was found to have Trichosporon asahii fungemia with widespread visceral dissemination, and his condition rapidly deteriorated despite treatment. It is important to consider trichosporonosis in the evaluation of a critically ill individual with neutropena and a rash, because the initial cutaneous presentation may appear benign and delayed therapy results in death.

Disseminated trichosporonosis with atypical histologic findings in a patient with acute lymphocytic leukemia

“…Histopathology classically reveals dermal fungal yeasts and hyphae on a background of mild‐to‐moderate, predominantly neutrophilic infiltrate. Perivascular or vasculitic involvement is also sometimes seen . Trichosporon shares morphologic characteristics with other common fungal pathogens but tends to present with a wider range of fungal elements at any one time (including hyphae, pseudohyphae, blastoconidia, and arthroconidia) .…”

“…Cutaneous T. asahii infections vary in presentation but manifest most commonly as purpuric, papulonodular, or pustular lesions with or without centralized necrosis. 2,5,6,13,14 Histopathology classically reveals dermal fungal yeasts and hyphae on a background of mild-tomoderate, predominantly neutrophilic infiltrate. Perivascular or vasculitic involvement is also sometimes seen.…”

“…Perivascular or vasculitic involvement is also sometimes seen. [2][3][4]13,14 Trichosporon shares morphologic characteristics with other common fungal pathogens but tends to present with a wider range of fungal elements at any one time (including hyphae, pseudohyphae, blastoconidia, and arthroconidia). 7 It has been suggested that Trichosporon has thinner hyphae and pseudohyphae as compared with Candida, and stains less prominently on GMS as compared with other fungi, but histopathological identification without the benefit of supplemental immunohistochemistry, enzyme-linked immunosorbent assay (ELISA), and/or polymerase chain reaction (PCR) analysis is difficult.…”

<p>An Overview of the Management of the Most Important Invasive Fungal Infections in Patients with Blood Malignancies</p>

“…The other risk factors leading to trichosporonosis are cytotoxic chemotherapy, consumption of systemic corticosteroid, indwelling central catheters, prosthetic valve surgery, organ transplantation, and peritoneal dialysis. 132,236 A recent systematic review reported that hematological diseases (38.9% of the cases), mainly acute leukemia, are the most frequent underlying diseases that provide a condition for invasive trichosporonosis (IT). Neutropenia was observed in 85% of patients with hematological diseases; this supports the fact that neutrophils are, as for aspergillosis and candidiasis, essential for the prevention of IT.…”

“… 131 Nguyen (2018) Trichosporon asahii Disseminated Infection 10-year-old boy with ALL Micafungin, AMB and voriconazole No Culture Died It is important to consider trichosporonosis in the evaluation of a critically ill individual with neutropenia and a rash, because the initial cutaneous presentation may appear benign and delayed therapy results in death. 132 Abbreviations: AMB, amphotericin B; LAMB, liposomal Amphotericin B; ALL, acute lymphocytic leukemia; AML, acute myeloid leukemia; CLL, chronic lymphocytic leukemia; PCR, polymerase chain reaction; MALDI-TOF MS, matrix-assisted laser desorption/ionization mass spectrometry; MRI, magnetic resonance imaging; HSCT, hematopoietic stem cell transplant; BAL, bronchoalveolar lavage; CT, computed tomography; HE, histopathologic examination; CSF, cerebrospinal fluid; MIC, minimum inhibitory concentration. …”