CANDIDA TROPICALIS FUNGEMIA IN AN ADOLESCENT PATIENT WITH SICKLE CELL DISEASE ON CRIZANLIZUMAB

Abstract

<h3>Introduction</h3> Crizanlizumab is a monoclonal antibody that blocks P-selectin on vascular endothelial cells and platelets. In sickle cell disease (SCD) P-selectin is upregulated promoting adhesion of endovascular cell clusters in vaso-occlusive crisis. Inhibition of P-selectin with crizanlizumab may decrease SCD vaso-occlusive crises. Given the role of P-selectin in neutrophil recruitment, we theorize P-selectin blockade with crizanlizuamb may pose an increased susceptibility to infection. We present a patient who developed fungemia and bacteremia while undergoing treatment with crizanlizumab. <h3>Case Description</h3> An adolescent patient with SCD and chronic pain, but no history of recurrent infections, was admitted for pain crisis. The patient was receiving intermittent crizanlizumab for 15 months, last given 7 weeks prior to admission. While hospitalized the patient developed fever and respiratory failure requiring intubation. Blood cultures grew <i>Candida tropicalis</i> and the patient was treated with micafungin. Over the course of a 2-month hospitalization, subsequent blood cultures grew multiple organisms including <i>Klebsiella pneumoniae, Lactobacillus, Enterococcus faecalis, Staphylococcus epidermidis, Staphylococcus warneri,</i> and <i>Candida glabrata</i>. The patient improved with antimicrobials and was discharged. <h3>Discussion</h3> <i>Candida tropicalis</i> fungemia is most common in patients with risk factors such as neutropenia, indwelling central lines, or malignancy, and not commonly associated with SCD thus representing an unusual infection for this patient without risk factors. Given a non-revealing and thorough immunological evaluation, we hypothesize that crizanlizumab may have led to a functional neutrophil defect, predisposing the patient to fungemia and bacteremia. Since stopping crizanlizumab, this patient has had pain-crises but has not suffered ongoing infectious complications.