Transcript University of Kansas Medical Center

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
 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
Lungs
Sinuses
Bone/joint
Eyes
Hands
Feet
CNS
Blood
Abdomen
59%
36%
8%
7%
4%
4%
3%
3%
2%
Cortez et. Al. Infections Caused by Scedosporium spp.
Clin Microbiol Rev. 2008 January; 21(1): 157–197.
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 Exam
T 36.7 BP 121/70 P 99 R 24 Pulse ox: 95% on room air
HEENT – Unremarkable
Chest – right sided indwelling Hickman catheter
Heart – Unremarkable
Lungs Diminished breath sounds bilaterally, no rales,
rhonchi, or wheezing
Abdomen: Unremarkable
Extremities/Skin: Unremarkable
Laboratory Data
 Fungitell: 257 (41 previously) [Normal < 40]
 Blood Culture: Scedosporium elements
The following were negative
Histoplasma Ab HIV screen
WBC
Hgb
12.9
12.3
Galactomannan
Aspergillus Ab
ANA
CMV, EBV pcr
RVP
Hep A,B,C
Plt
Neut
INR
239
80%
3.4
Scl70
Anti-dsDNA
Mycoplasma
Chlamydia
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
 Caspofungin
 Micafungin
 Voriconazole
 Itraconazole
 Posaconazole
R
R
S
S
S
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
Acknowledgments
Dr. 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 IκBα
X–linked lymphoproliferative syndrome
DeVries et.al. Clinical & Experimental Immunology vol. 145, iss. 2.
pages 204–214, August 2006