Ann Hematol (1996) 73 : 33–34 Q Springer-Verlag 1996 CASE REPORT L. Pagano 7 G. Morace 7 E. Ortu-La Barbera M. Sanguinetti 7 G. Leone Adjuvant therapy with rhGM-CSF for the treatment of Blastoschizomyces capitatus systemic infection in a patient with acute myeloid leukemia Received: 30 November 1995 / Accepted: 4 April 1996 This work was supported by a CNR grant, Targeted Project “ACRO,” no. 95.00402. PF 39. L. Pagano (Y) 7 E. Ortu-La Barbera 7 G. Leone Istituto di Semeiotica Medica, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, I-00168 Rome, Italy G. Morace 7 M. Sanguinetti Istituto di Microbiologia, Università Cattolica del Sacro Cuore, Rome, Italy Abstract We report a patient with acute myeloid leu- kemia and Blastoschizomyces capitatus sepsis who de- veloped multiple abscesses when neutrophils recoved. The patient did not respond to antifungal therapy and her clinical condition showed an improvement only af- ter rhGM-CSF was added to the treatment. Key words Leukemia 7 Blastoschizomyces 7 rhGM-CSF Introduction Invasive fungal infections are one of the major causes of morbidity and death in patients with acute leukemia. The main fungal agents seen in neutropenic patients are Candida and Aspergillus species, although other fungi such as Cryptococcus, Zygomycetes, Trichosporon are increasing in incidence [9]. The most important manifestation of fungal infec- tion is fungemia, characterized by a high mortality [7]. Candida sepsis is frequently encountered while Tri- chosporon sepsis is only sporadically reported [2, 5, 6, 8]. Here we report a patient with acute myeloid leu- kemia (AML) who recovered from a Blastoschizo- myces capitatus systemic infection only after the addi- tion of recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) to the antifun- gal treatment. Case report A 57-year-old woman affected by AML (FAB M4) was admitted to our Division of Hematology on December 2, 1994, for consoli- dation therapy including idarubicin (10 mg/m 2 days 1–6) plus ara- cytin (500 mg/m 2 days 1–6). A week after the end of chemothera- py she presented with a diffuse rash with itching, followed after 5 days by high fever (40 7C). She was started on broad-spectrum an- tibiotics (aminoglycoside plus cephalosporin plus glycopeptide). At that time the neutrophil count was lower than 0.1!10 9 /l. The patient did not have a central venous catheter (CVC) and was not on total parenteral nutrition or corticosteroid treatment. After 4 days of constantly high fever, on December 26, 1994, she was started on empirical antifungal treatment with amphotericin B (Amb) at a dosage of 0.8 mg/kg/day. At the same time she showed diffuse cutaneous papulae. A biopsy of a lesion demon- strated the presence of a Blastoschizomyces capitatus, which was then identified in four consecutive blood cultures. Antimycotic sensitivity was tested in vitro and Blastoschizomyces proved sensi- tive to Amb, 5-fluorocytosine (5-Flu), itraconazole, and ketocona- zole and resistant to fluconazole. The patient continued to receive antifungal therapy with Amb at a dosage of 1.2 mg/kg/day, and on January 16, 1995, the day after the increase of neutrophils to `1!10 9 /l, she presented with left hemiparesis, stupor, and dysp- nea. A total-body CT scan showed multiple abscesses to both lungs and kidneys, spleen, liver, and the central nervous system (CNS). CNS magnetic resonance imaging (MRI) showed lenti- form nucleus involvement (Fig. 1). Bone marrow examination de- monstrated a blastic infiltration of less than 5%, and a hemo- gram showed only a marked thrombocytopenia (WBC 5.3!10 9 /l, neutrophils 4.2!10 9 /l, platelet count 34!10 9 /l). A renal biopsy demonstrated the mycotic etiology of the abscesses. After 20 days on Amb treatment with no improvement in her clinical con- dition, 5-Flu was added. On April 2, 1995, after a cumulative dose of 2.2 g Amb and 76 g 5-Flu, a new total-body CT scan showed unmodified abscesses. A new bone marrow examination showed good cellularity with a blastic infiltration of less than 5% and presence of megakaryocytes. The hemogram showed the persis- tence of peripheral thrombocytogenic (23!10 9 /l). The patient was started on rhGM-CSF treatment at a dose of 300 mg s.c., 3 times a week. After 4 weeks on therapy (cumulative Amb dose, 4.1 g), a new CT scan showed a marked reduction of abdominal, pulmon- ary, and neurological abscesses. At the same time her platelet count increased and her WBC count was stable (WBC 9!10 9 /l, neutrophils 6.7!10 9 /l, platelets 70!10 9 /l). The rhGM-CSF was well tolerated, without major toxicity, and on May 5, 1995, the patient was discharged in complete hematological remission (CR) on treatment with 5-Flu plus rhGM-CSF 150 mg twice a week, af- ter a total dose of 5.2 g Amb. The antifungal treatment was stop- ped (total dose of 128 g 5-Flu) on August 28, 1995, and the pa- tient received no further antineoplastic therapy. On September 14, 1995, a new bone marrow examination confirmed the CR, and another total-body CT scan and MRI of the CNS showed the cal- cification of abscesses (Fig. 2). The hemogram showed a normal