Despite prolonged therapy of Amphotericin B , the patient ’ s small bowel perforated and he soon passed . 5 Although rare , the immunocompetent patient is not without risk .
Fungal Infections in the Immunocompromised
Classically , Candida has caused the majority of infections . With the increasing use of antifungal prophylaxis , like Fluconazole , Aspergillus is increasingly becoming the dominant agent . Candida was seen in 8-25 % of patients with hematologic malignancies when patients were not on antifungal prophylaxis . 6 Aspergillus has been observed in 2 to 28 % of hematologic malignancy patients . 7 In Invasive Aspergillus , the respiratory tract is the most common site infected due to inhaled spores . Other organs involved in 10-25 % of cases are the liver , kidney , brain , GI , and skin . 8 Focal extrapulmonary IA is very uncommon . 9
Invasive Aspergillosis
Aspergillus spores are aerosolized and inhaled . In an immunocompromised patient , inhaled conidia colonize the respiratory system and penetrate the bloodstream causing disseminated infection . In pulmonary aspergillosis , the classic triad of symptoms are fever , pleuritic chest pain , and hemoptysis in the neutropenic patient . The most common presentation is simply a prolonged fever of four days in the setting of neutropenia . The ingestion of Aspergillus spores could be an alternate route of infection . 10 Typically , Aspergillus cannot infect the mucosa of the GI tract , but several chemotherapeutic agents increase the risk of mucositis , which provides a favorable environment for spore invasion .
The gold standard for diagnosis of hematogenous Aspergillus infections is a fungal blood culture . A . fumigatus infections , the most common , are often culture negative , especially early in the disease . 8 Direct microscopy sensitivity is quite variable ranging from 0 to 90 %. 8 Histopathology of infected tissues will show only fungal forms and are not diagnostic of the specific fungal species . Nonculture methods such as antigen assays are required to diagnose IA . 8
Treatment is based on three components : antifungal therapy , immunosuppression , and surgery . Initially , a Voriconazole regimen is recommended ( Grade 1A ). Voriconazole has a greater likelihood of response , low mortality , and less adverse reactions . 9 There is some debate on the addition of echinocandins , so the choice is institution dependent . Alternatively , Amphotericin B can be used , as Voriconazole is often limited by hepatotoxicity . Duration of therapy is dependent on location of infection , underlying disease process , and amount of immunosuppression required during therapy . There is no recommended regimen for extrapulmonary IA due to the rarity of presentation . 9 Voriconazole is the recommended primary treatment , but therapy is often modified for a salvage approach . Typically , antifungal therapy willcontinue for many months .
The degree of immunosuppression should be decreased during treatment of the fungal infection . Fewer patients with severe suppression had a response to therapy when compared to less suppression . 9
Surgical debridement is dependent on location of the infection , amount of tissue involved , and the patient ’ s ability to tolerate surgery . In cases where necrotic tissue limits antifungal efficacy or local vasculature is threatened , surgery is indicated . In this case , surgical therapy was necessary to prevent hemorrhage and perforation . Outcomes for IA are variable in the literature , with mortality ranging from 35 % to over 94 %. 8
Conclusion
Focal extrapulmonary IA is uncommon and only appears in the setting of case reports . It must be managed with antifungals , surgery , and lessening of immunosuppression . We presented an immunosuppressed patient with clinical findings consistent with appendicitis . Following appendectomy , a diagnosis of IA was made , and he was treated with antifungal therapy . The patient recovered well and has continued MM treatment .
Physicians should be aware of the possibility of fungal appendicitis in the immunosuppressed , and of appropriate therapy due to the high potential for poor outcomes .
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Physicians should be aware of the possibility of fungal appendicitis in the immunosuppressed , and of appropriate therapy due to the high potential for poor outcomes .
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6 . Rotstein C , Bow EJ , Laverdiere M , Ioannou S , Carr D , Moghaddam N . Randomized placebocontrolled trial of fluconazole prophylaxis for neutropenic cancer patients : benefit based on purpose and intensity of cytotoxic therapy . The Canadian Fluconazole Prophylaxis Study Group . Clinical infectious diseases : an official publication of the Infectious Diseases Society of America . 1999 ; 28 ( 2 ): 331-40 .
7 . Wirk B , Wingard JR . Current approaches in antifungal prophylaxis in high risk hematologic malignancy and hematopoietic stem cell transplant patients . Mycopathologia . 2009 ; 168 ( 6 ): 299-311 .
8 . Barton RC . Laboratory diagnosis of invasive aspergillosis : from diagnosis to prediction of outcome . Scientifica . 2013 ; 2013:459405 .
9 . Walsh TJ , Anaissie EJ , Denning DW , Herbrecht R , Kontoyiannis DP , Marr KA , et al . Treatment of aspergillosis : clinical practice guidelines of the Infectious Diseases Society of America . Clinical infectious diseases : an official publication of the Infectious Diseases Society of America . 2008 ; 46 ( 3 ): 327-60 .
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