Fusarium verticillioides Abscess of the Nasal Septum in an Immunosuppressed Child: Case Report and Identification of the Morphologically Atypical Fungal Strain

Abstract

Morphologically atypical Fusarium verticillioides causing a nasal abscess in a severely immunosuppressed child was successfully treated with repeated surgical intervention and liposomal amphotericin B, despite amphotericin B resistance in vitro. Definitive identification was achieved by sequencing the translation elongation factor ␣ gene after ribosomal sequencing proved inadequate. CASE REPORTA 9-year-old boy diagnosed with chronic myelogenous leukemia in September 2001 had been treated with imatinib (STI 571) for 9 months and achieved hematologic and cytogenetic remission. After allogeneic bone marrow transplantation in June 2002, he developed severe chronic graft-versus-host disease (GvHD) involving the skin, the liver, and the gastrointestinal tract. GvHD was accompanied by dryness of the eyes, nose, and mouth, which frequently made the patient feel compelled to pick his nose despite moistening measures. Under immunosuppression with cyclosporine, mycophenolate mofetil, prednisolone, and budesonide, the patient required repeated courses of antiviral treatment for the reactivation of cytomegalovirus (CMV), human herpesvirus 6, and Epstein-Barr virus, revealed by PCR in his blood. He experienced several febrile episodes, most of which responded to broad-spectrum antibacterial agents, except for one episode which required the addition of antifungal treatment with liposomal amphotericin B (LAMB). While receiving antimicrobial prophylaxis with oral penicillin V (for functional hyposplenia) and intravenous caspofungin, the patient became febrile again on day 579 after bone marrow transplant and exhibited a slight increase of C-reactive protein (CRP) and leukocytosis (18,600/l) with a marked left shift. An intranasal tumor protruding through both nostrils was observed. Ear, nose, and throat evaluation revealed a fluctuant mass on both sides of the cartilaginous nasal septum, with partial destruction of the cartilage shown by computed tomography (CT) imaging (Fig. 1). Hemorrhagic and purulent fluid was aspirated, and antibiotic treatment with piperacillin and tazobactam was started. A cytologic examination revealed no signs of malignancy nor the presence of microorganisms. The patient remained febrile, and CRP increased to a maximum of 58 mg/liter. When the microbiology lab reported the growth of a fungal species 2 days after abscess drainage, caspofungin was replaced by LAMB at a dose of 6 mg kg of body weight Ϫ1 day Ϫ1 . Culture on Sabouraud glucose agar and microscopy revealed features suggestive of Fusarium spp. In the following days, the patient, still under immunosuppressive treatment with cyclosporine, mycophenolate mofetil, and corticosteroids, markedly improved, with defervescence as well as normalization of CRP and granulocyte counts. One week after the operation, his nasal respiration gradually deteriorated again, and bilateral swelling at the anterior nasal septum required another drainage 13 days after the first surgical intervention. Debridement of the fungal focus was not performed in order to avoid di...

Nasal septal abscess in children: From diagnosis to management and prevention

“…Five years later, another case of NSA in a 9-year-old patient -with severe chronic graft-versus-host disease following allogenic bone marrow transplantation as a treatment for chronic myelogenous leukemia -was reported. The cause of NSA was repetitive nasal trauma caused by dryness-induced nose picking [36]. Although this case and the five cases presented earlier were in immunocompromised patients, there was a well-documented eliciting cause for NSA formation in each one of them, and thus, were not truly spontaneous in nature [35,36].…”

Phaeoacremonium parasiticum Infections Confirmed by β-Tubulin Sequence Analysis of Case Isolates

“…It was suggested that the optimal method for identification both at the scientific level and, where convenient, at the diagnostic level was to use sequences of selected regions of the ␤-tubulin gene, in addition to sufficient phenotypic characterization to corroborate the sequencing result (20). This recommendation for Phaeoacremonium resembles those made (explicitly or by implication) for several other genera of very simply structured phialidic and annellidic opportunistic fungi, such as Exophiala (4), Trichoderma (24), and Fusarium (5,13). These are all genera where numerous new morphologically poorly distinguished phylogenetic species causing human infection are being described and where full species identification increasingly relies on sequencing or related molecular studies.…”

Treatment of murine Fusarium verticillioides infection with liposomal amphotericin B plus terbinafine

“…In the clinical setting there are few, and contradictory, data on the use of L-AmB for treatment of F. verticillioides infection. Whilst this drug showed satisfactory results following failure of AmB in two cases of disseminated infection [17,18], in a recent case of disseminated infection by the same fungus L-AmB given alone was unable to resolve the infection, which was cured when voriconazole was added to the treatment [19]. We observed a poor correlation between in vitro results and the in vivo efficacy of TRB in a murine model.…”