CLINICAL
AND
LABORATORY OBSERVATIONS
Brain Abscesses Due to Aspergillus nidulans Infection During Induction Chemotherapy for Acute Lymphoblastic Leukemia Manish Sadarangani, BM, BCh, MRCPCH, DPhil,*w Melissa Harvey, MD, FRCPC,z Allison McDonald, PhD,y David P. Speert, MD, FRCP(C),*y and David Dix, MB, ChB, FRCPC, FAAPz
Summary: We present the case of a 3-year-old boy who was diagnosed with cerebral abscesses due to Aspergillus nidulans infection on day 28 of induction chemotherapy for acute lymphoblastic leukemia. He responded well to treatment with voriconazole and caspofungin, making a full recovery. There are very few cases of invasive aspergillosis reported in children during induction chemotherapy for acute leukemia and A. nidulans is rare in the absence of chronic granulomatous disease. Key Words: acute lymphoblastic leukemia, aspergillosis, cerebral abscess, chemotherapy, fungal
(J Pediatr Hematol Oncol 2015;37:e384–e386)
CASE DESCRIPTON A previously healthy 3-year-old boy was diagnosed with acute lymphoblastic leukemia (ALL) after a 1-week history of fever, leg pain, spontaneous bruising, and a petechial rash. A complete blood count showed white blood cells 40 109/L, hemoglobin 93 g/L, platelets 44 109/L, and blast cells seen on the peripheral smear. A bone marrow aspirate and biopsy confirmed B-precursor ALL. Cerebrospinal fluid (CSF) findings were normal. The patient was stratified as “average risk” based on his presenting features and bone marrow cytogenetic analysis. He commenced chemotherapy according to protocol AALL0932, consisting of induction therapy with intravenous (IV) vincristine on days 1, 8, 15, and 22, IV pegasparaginase on day 4, intrathecal (IT) cytarabine on day 1, IT methotrexate on days 8 and 29, and daily dexamethasone (IV or orally) on days 1 to 28. On day 28 of chemotherapy, the child underwent a routine lumbar puncture for administration of methotrexate and was unexpectedly found to have an abnormal CSF profile: CSF white blood cells 2610 106/L (91% neutrophils) (normal, 0 to 4106/L), CSF protein 0.46 g/L (normal, 0 to 0.40 g/L), and CSF glucose 2.1 mmol/L (normal, 2.4 to 5.6 mmol/L). No organisms were seen on the Gram stain and subsequent blood, CSF, and urine cultures were negative. The patient was admitted to hospital at which time Received for publication November 2, 2014; accepted April 13, 2015. From the *Department of Paediatrics, Division of Infectious Diseases; zDepartment of Paediatrics, Division of Hematology and Oncology, University of British Columbia and BC Children’s Hospital; yChild and Family Research Institute, Vancouver, BC, Canada; and wDepartment of Paediatrics, University of Oxford, Oxford, UK. The authors declare no conflict of interest. Reprints: Manish Sadarangani, BM, BCh, MRCPCH, DPhil, Department of Paediatrics, University of Oxford, Level 2, Children’s Hospital, Headley Way, Headington, Oxford OX3 9DU, UK (e-mail: [email protected]). Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Website, www. jpho-online.com. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
he appeared well with no localizing symptoms or signs to suggest a focus of infection, and no significant unusual exposures to animals or other sick people. He also had a normal complete blood count, was not neutropenic, and his C-reactive protein was
AND
LABORATORY OBSERVATIONS
Brain Abscesses Due to Aspergillus nidulans Infection During Induction Chemotherapy for Acute Lymphoblastic Leukemia Manish Sadarangani, BM, BCh, MRCPCH, DPhil,*w Melissa Harvey, MD, FRCPC,z Allison McDonald, PhD,y David P. Speert, MD, FRCP(C),*y and David Dix, MB, ChB, FRCPC, FAAPz
Summary: We present the case of a 3-year-old boy who was diagnosed with cerebral abscesses due to Aspergillus nidulans infection on day 28 of induction chemotherapy for acute lymphoblastic leukemia. He responded well to treatment with voriconazole and caspofungin, making a full recovery. There are very few cases of invasive aspergillosis reported in children during induction chemotherapy for acute leukemia and A. nidulans is rare in the absence of chronic granulomatous disease. Key Words: acute lymphoblastic leukemia, aspergillosis, cerebral abscess, chemotherapy, fungal
(J Pediatr Hematol Oncol 2015;37:e384–e386)
CASE DESCRIPTON A previously healthy 3-year-old boy was diagnosed with acute lymphoblastic leukemia (ALL) after a 1-week history of fever, leg pain, spontaneous bruising, and a petechial rash. A complete blood count showed white blood cells 40 109/L, hemoglobin 93 g/L, platelets 44 109/L, and blast cells seen on the peripheral smear. A bone marrow aspirate and biopsy confirmed B-precursor ALL. Cerebrospinal fluid (CSF) findings were normal. The patient was stratified as “average risk” based on his presenting features and bone marrow cytogenetic analysis. He commenced chemotherapy according to protocol AALL0932, consisting of induction therapy with intravenous (IV) vincristine on days 1, 8, 15, and 22, IV pegasparaginase on day 4, intrathecal (IT) cytarabine on day 1, IT methotrexate on days 8 and 29, and daily dexamethasone (IV or orally) on days 1 to 28. On day 28 of chemotherapy, the child underwent a routine lumbar puncture for administration of methotrexate and was unexpectedly found to have an abnormal CSF profile: CSF white blood cells 2610 106/L (91% neutrophils) (normal, 0 to 4106/L), CSF protein 0.46 g/L (normal, 0 to 0.40 g/L), and CSF glucose 2.1 mmol/L (normal, 2.4 to 5.6 mmol/L). No organisms were seen on the Gram stain and subsequent blood, CSF, and urine cultures were negative. The patient was admitted to hospital at which time Received for publication November 2, 2014; accepted April 13, 2015. From the *Department of Paediatrics, Division of Infectious Diseases; zDepartment of Paediatrics, Division of Hematology and Oncology, University of British Columbia and BC Children’s Hospital; yChild and Family Research Institute, Vancouver, BC, Canada; and wDepartment of Paediatrics, University of Oxford, Oxford, UK. The authors declare no conflict of interest. Reprints: Manish Sadarangani, BM, BCh, MRCPCH, DPhil, Department of Paediatrics, University of Oxford, Level 2, Children’s Hospital, Headley Way, Headington, Oxford OX3 9DU, UK (e-mail: [email protected]). Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Website, www. jpho-online.com. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
he appeared well with no localizing symptoms or signs to suggest a focus of infection, and no significant unusual exposures to animals or other sick people. He also had a normal complete blood count, was not neutropenic, and his C-reactive protein was
