A case of cutaneous penicilliosis in a child with acute myeloid leukaemia

Sandhya G Krishnan,Ah Moy Tan,Natalie Woon Hui Tan,Mark Jean Aan Koh,Koh Cheng Thoon,Chia Yin Chong,Ai Ling Tan,Nancy Wen Sim Tee

doi:10.1099/jmmcr.0.000098

Abstract

Introduction: We present a case of cutaneous penicilliosis in a paediatric patient with acute myeloid leukaemia (AML). Case report: A 2-year-old boy with AML first developed probable pulmonary aspergillosis during induction chemotherapy in an overseas centre in May 2013, and was treated with AmBisome and voriconazole. When he was admitted to our centre with relapsed AML in October 2013, he was given a fifth course of chemotherapy, and treated with AmBisome for probable pulmonary aspergillosis in view of pulmonary nodular opacities on computed tomography. He thereafter developed an erythematous skin lesion with central eschar on his right hand and left calf. Serum and bronchoalveolar lavage galactomannan antigen (GM Ag) indices increased to a value of >10. AmBisome was changed to voriconazole, and caspofungin was added for 10 days. The left calf skin biopsy showed abundant fungal hyphae with septations. A skin culture grew Penicillium citrinum with MICs (μg ml− 1) of: caspofungin 0.016, itraconazole 0.5, amphotericin 1.5 and voriconazole >256.Caspofungin and itraconazole were commenced, and voriconazole was discontinued. The skin lesions and serial GM Ag indices improved. The patient later developed increasing GM Ag indices to a value of >10, which was attributed to Aspergillus flavus left pulmonary mycetoma, which was surgically resected. He eventually succumbed to relapsed AML after a bone-marrow transplant. Conclusion: To the best of our knowledge, this is the first paediatric case of P. citrinum infection. Rising GM Ag indices were attributed to cross-reactivity of Penicillium spp. with GM Ag enzyme immunoassays.

Highlights

We present a case of cutaneous penicilliosis in a paediatric patient with acute myeloid leukaemia (AML).Case report: A 2-year-old boy with AML first developed probable pulmonary aspergillosis during induction chemotherapy in an overseas centre in May 2013, and was treated with AmBisome and voriconazole
To the best of our knowledge, we report here what we believe is the first paediatric case of P. citrinum infection and we investigated the diagnosis and treatment of the infection in this patient
P. citrinum has only been reported in a handful of cases, causing urinary tract infection (Guze & Haley, 1958), mycotic keratitis (Gugnani et al, 1978), bronchopulmonary infection (Mori et al, 1987), pneumonia with pericarditis in a patient with acute leukaemia (Mok et al, 1997) and chronic sinusitis (Twaruzek et al, 2014)

Summary

Introduction

With the increasing prevalence of primary and secondary immunodeficiency, e.g. AIDS, and the increasing use of Downloaded from www.microbiologyresearch.org by. He received four chemotherapy cycles as per the Children Oncology Group Australia Acute Myeloid Leukaemia Protocol (COGAAML 531) consisting of cytarabine, daunorubicin, etoposide and mitoxantrone During his induction chemotherapy, a computed tomography (CT) scan of his thorax showed a nodule containing an air-fluid level in the anterior right upper lobe and peripheral peribronchial changes, highly suggestive of a fungal infection. The MICs (mg ml21) were 0.016 for caspofungin, 0.5 for itraconazole, 1.5 for amphotericin and w256 for voriconazole At this juncture, a CT of his thorax showed a left upper lobe nodule with peripheral cavitation suggestive of mycetoma and right pleural thickening with a small pleural effusion. Subsequent CT of the thorax showed a left upper lobe nodule with internal air-fluid level and a stable right-sided effusion. His AML relapsed and he died in early 2015

Conclusion

Discussion