Acanthamoeba infection in a patient with chronic graft‐versus‐host disease occurring during treatment with voriconazole

Abstract

We report a case of disseminated infection with Acanthamoeba in a patient with graft-versus-host disease after hematopoietic stem cell transplant (HSCT) for acute lymphocytic leukemia. The infection involved the brain, skin, and lungs and occurred despite treatment with voriconazole for mold prophylaxis, and did not respond to treatment with multiple other agents reported to have activity against Acanthamoeba. To our knowledge, infection with Acanthamoeba has been reported in 4 other patients after HSCT or bone marrow transplant, and our case is the first to be diagnosed ante-mortem.

Ante mortem diagnosis of amoebic encephalitis in a haematopoietic stem cell transplanted patient

“…Recently, cases of amoebic meningoencephalitis have been found in healthy persons [7] and in haematopoietic stem cell transplanted patients [2,5,9,13]. It seems that recipients of HSCT may be at increased risk for life-threatening amoebic infections as well as the difficulty in making an ante mortem diagnosis of GAE.…”

Dermatologic Infections in Cancer Patients

“…In immunocompromised hosts, the most common manifestation of disease is subacute meningoencephalitis [33]. Skin lesions have rarely been reported, as in a patient with acute lymphocytic leukemia who developed extensive GVHD and became septic, with papular, ulcerative lesions on his face and extremities; histology of these sites confirmed presence of Acanthamoeba, despite being on prophylactic therapy with voriconazole.…”

“…The patient was started on liposomal amphotericin B (5 mg/kg) daily in combination with trimethoprim-sulfamethoxazole (5 mg/kg of the trimethoprim component) every 8 h, but patient expired 5 weeks after diagnosis. Risk factors for development of this infection include: solid organ transplantation, connective tissue disease, diabetes, cirrhosis, renal failure, malignancy, and tuberculosis [33].…”

Risk-based antifungal prophylaxis in hematologic malignancy and stem cell transplantation

“…Reports also exist of proven breakthrough infections in patients receiving other agents for MAP, including voriconazole and echinocandins [42,43]. A retrospective review of HSCT patients receiving voriconazole prophylaxis showed that although IA was rare, zygomycosis occurred in 6% of patients and invasive candidiasis in 8% [44].…”