Severe conidiobolomycosis complicating induction chemotherapy in a patient with acute lymphoblastic leukaemia

Abstract

The patient, a 20-year-old male, was a full-time soldier and actively involved in field training when diagnosed with acute lymphoblastic leukaemia. Induction chemotherapy, consisting of vincristine, cyclophosphamide, adriamycin and dexamethasone, was given together with itraconazole 200 mg q.i.d. as fungal prophylaxis. He became neutropenic 13 d after commencing chemotherapy and on d15, developed acute onset of right facial and cervical swelling associated with stridor, which required endoscopic-guided intubation to protect his airways. A contrast-enhanced computed tomography (top left) showed the presence of a large right paratonsillar abscess with inflammatory response extending to the right masseter and parotid spaces, resulting in airway obstruction. He subsequently developed a collapse of the entire left lung because of an obstructive plaque in the left main stem bronchus (top right). A bronchoscopic biopsy of the lesion was initially suggestive of aspergillus tracheobronchitis and empirical treatment with caspofungin was commenced, as the concomitant occurrence of acute renal failure and ischemic hepatitis precluded the use of amphotericin or voriconazole. The patient made a striking recovery and was extubated 4 d later with an associated recovery of neutrophils. However, the correct diagnosis was only established when the causative organism was identified as Conidiobolus coronatus. Microscopically (bottom), sporangiola producing secondary multiplicative spores were seen. Conidiobolus coronatus is a saprophyte in soil or organic debris in a tropical environment and typically causes localized nasal and soft tissue infections in animals and rarely in humans. There is still no consensus on the most appropriate anti-fungal treatment. The social background of a patient may play an important role in the pathogenesis of opportunistic infections in an immunocompromised host.