atypical presentation of scedosporium pneumonia
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Atypical Presentation of Scedosporium Pneumonia. Gabriel Johnson, DO Leslie Spikes, MD Department of Internal Medicine University of Kansas Medical Center Kansas City, KS. Introduction. Provide a brief overview of scedosporium epidemiology - PowerPoint PPT PresentationTRANSCRIPT
Atypical Presentation of Scedosporium Pneumonia
Gabriel Johnson, DOLeslie Spikes, MD
Department of Internal MedicineUniversity of Kansas Medical Center
Kansas City, KS
Introduction Provide a brief overview of scedosporium
epidemiology
Present an unusual case of a life-threatening Scedosporium infection in a patient without typical risk factors for fungemia
Identify diagnostic and therapeutic challenges
Scedosporium Infections in Humans Localized infections:
Bronchiectatic lungs Mycetomas
Disseminated infections: Transplant wards
Up to 10% of cystic fibrosis patients colonized in transplant wards
Near drowning events Rarely in the immuno-competent
Cortez et. Al. Infections Caused by Scedosporium spp. Clin Microbiol Rev. 2008 January; 21(1): 157–197.
Complication of organ transplant Study of 80 cases of scedosporium infection in
transplant patients at 5 academic institutions
23 hematopoietic stem cell transplants 57 solid organ transplants
Disseminated infection 2 noncontiguous organs or + blood culture 69% of HSCT with scedosporium 53% of SOT with scedosporium
Husein et. al. Infections due to Scedosporium in Transplant Recipients: Clinical Characteristics. Clinical Infectious Disease 2005 Jan 1;40
Scedosporium - overview Ubiquitous white mold
Tolerates aerobic and anaerobic conditions and wide range of temperature and osmolarity
Transmission Direct inoculation (mycetoma) Inhalation of airborne particles
Williamson et. al. Genetic Epidemiogy of Scedosporium in Patients with Chronic Lung Disease. J Clin Microbiol. 2001 January; 39(1): 47–50.
Species Scedosporium apiospermum
Typically sensitive to multi-agent antifungal therapy
Voriconazole associated with survival improvement over amphotericin
Scedosporium prolificans Treatment generally requires immunosuppression
reversal and surgical intervention.
Cortez et. Al. Infections Caused by Scedosporium spp. Clin Microbiol Rev. 2008 January; 21(1): 157–197.
American Society for Microbiology: Clinical Microbiology Reviews
Infection sites 2000-2007
Cortez et. Al. Infections Caused by Scedosporium spp. Clin Microbiol Rev. 2008 January; 21(1): 157–197.
Lungs 59%Sinuses 36%Bone/joint 8%Eyes 7%Hands 4%Feet 4%CNS 3%Blood 3%Abdomen 2%
Case Report A 72 year old woman presented to ER
3 months of progressive hemoptysis
Diffuse pulmonary nodules on recent imaging
5 days of fever, chills, and myalgias
Past Medical History Pulmonary arterial hypertension
Diagnosed 2 years prior Likely secondary to chronic pulmonary emboli On continuous infusion intravenous treprostinil On warfarin for chronic thromboemboli
Breast cancer Right mastectomy and radiation 8 years prior
No history of atypical or recurrent infections
Recent Medical History CT guided needle biopsy of pulmonary nodule had
been performed 3 weeks prior
Histology: necrotic tissue, peribronchial fibrosis and chronic inflammatory changes without granulomas
Gram stain/culture: no bacterial or fungal growth
Cytology: no malignant cells
Social History Independently performs activities of daily living
25 pack years but quit 2 years prior
No occupational or environmental exposures
Physical ExamT 36.7 BP 121/70 P 99 R 24 Pulse ox: 95% on room air
HEENT – UnremarkableChest – right sided indwelling Hickman catheterHeart – UnremarkableLungs Diminished breath sounds bilaterally, no rales, rhonchi, or wheezingAbdomen: UnremarkableExtremities/Skin: Unremarkable
Laboratory Data Fungitell: 257 (41 previously) [Normal < 40] Blood Culture: Scedosporium elements
WBC 12.9Hgb 12.3Plt 239Neut 80%INR 3.4
Histoplasma Ab HIV screenGalactomannan CMV, EBV pcrAspergillus Ab RVPANA Hep A,B,CScl70 MycoplasmaAnti-dsDNA Chlamydia
The following were negative
3 weeks prior
Hospital Course Sudden hemoptysis of 600 ml frank blood
Resolved with reversal of anticoagulation
Bronchoscopy with lavage performed Hemorrhagic fluid with negative cultures
Repeat CT guided biopsy of left lobe nodule Pathologic findings unchanged and unremarkable
Hickman catheter removed No fungal or bacterial growth on tip culture
Hospital Course Amphotericin and voriconazole initiated
Repeat CT 2 weeks later showed progression
Patient requested to discontinue all IV medications and go home with home health care Oral voriconazole and terbinafine Oral sildenafil New 2 L oxygen requirement
Speciation and Sensitivity Speciation: Scedosporium Apiospermum
Sensitivity testing: Amphotericin R Caspofungin R Micafungin S Voriconazole S Itraconazole S Posaconazole S
Resolution Patient’s hypoxia improved and she was able to
titrate off oxygen
No recurrence of fever or hemoptysis
She completed 6 months of antifungal therapy with voriconazole and terbinafine
Radiographic regression
4 months later
Case Summary Atypical presentation of a rare fungal pathogen
Diagnostic difficulties
Voriconazole as preferred agent
Questioning her risk factors
AcknowledgmentsDr. Leslie Spikes
Associate Professor of Internal Medicine University of Kansas Medical Center
European Society for Imunodeficiencies
Unusual infections or unusually severe course of infections
T lymphocyte deficiency WAS STAT1 deficiency Hypermorphic mutations in IκBαX–linked lymphoproliferative syndrome
DeVries et.al. Clinical & Experimental Immunology vol. 145, iss. 2.pages 204–214, August 2006