P194 Disseminated fusariosis in h ematological malignancies with favo rable outcomes
Authors: Fernandez Norma B. , Farias Luciana , Hevia Alejandra , Cordoba Susana , Abrantes Ruben , Bogdanowicz Elizabeth , Sierra Mariela 
Published: September 2022

Abstract

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM
Fusarium is a serious fungal disease that mainly affects high-risk hematological patients. Early recognition of cutaneous entry of Fusarium in severely immunocompromised patients is critical to initiate early treatment.
The aim of this presentation is to present two cases of disseminated fusariosis in severe oncohematological patients with favorable outcomes.
Case 1: A 65-year-old man was admitted to the hospital for allogeneic hematopoietic cell transplantation. He had chronic myelomonocytic leukemia treated with cytosine analog antineoplastic and received pre-transplant prophylaxis with voriconazole 400 mg/day. On day 8 after transplantation, he presented pain and erythema on the fifth toe. Scarification of the digital intertrigo showed fine septate hyaline filaments. Antifungal treatment with voriconazole 400 mg/day plus liposomal amphotericin B 5 mg/k/d was administered. The patient remained severely neutropenic and the digital lesion progressed to painful necrosis for the following 12 days. BACTEC blood culture developed F. keratoplasticum and MIC (mg/L) amphotericin B 1, voriconazole 8 (CLSI M38-3rd Ed). On day 24 post-transplant, the patient presented an erythematous lesion on the right leg. A toilette of the digital lesion and a skin biopsy of the lesion on the right leg was performed, both of which showed fine hyaline filaments on direct examination with negative culture. On day 55, the patient was stable and amphotericin B was discontinued. He was treated with voriconazole 400 mg/d and had a good clinical evolution. The patient was discharged 65 days after transplantation.
Case 2: An 18-year-old man was admitted to the hospital for chemotherapy treatment for acute lymphocytic leukemia (ALL). The patient received prophylaxis with fluconazole. On day 15 after chemotherapy, he developed Candida parapsilosis candidemia; C.parapsilosis MIC (mg/L) amphotericin B 1, fluconazole 0.5, voriconazole 0.015; anidulafungin 0.4 (E Def 7.32.EUCAST). The patient was treated with anidulafungin. He remained febrile and neutropenic. On the 19th day, he presented a digital intertrigo on the foot. Direct examination of the scarification of the interdigital lesion showed fine hyaline filaments and the colony was identified as F. solani complex, MIC (mg/L) amphotericin B 2, voriconazole 8 (M 38 3rd Ed CLSI). The antifungal treatment was changed to voriconazole 400 mg/d and lipid complex amphotericin B 5 mg/kg/d. On day 22, he was still neutropenic and febrile. Chest and sinus CT scans showed no abnormalities. Blood cultures and BAL culture were negative. The patient developed multiple ecthyma gangrenosum skin lesions on the torso and legs. On day 35, he received a granulocyte transfusion. On days 42 and 44, the serum GM Aspergillus was 0.2 and 0.4 respectively. On day 45, he presented a nasal lesion. The nasal biopsy showed a positive direct examination and development of the F. solani complex. On day 47, a surgical toilette of the foot lesion was performed. The patient had a favorable outcome with voriconazole 400 mg/day until hematopoietic cell transplantation.

Conclusion
Evaluation of skin lesions in severely immunocompromised patients allows prompt diagnosis for antifungal treatment and appropriate debridement in patients with a proven mycological diagnosis of disseminated fusariosis.