Bone Marrow Transplantation, (1997) 20, 789–791  1997 Stockton Press All rights reserved 0268–3369/97 $12.00 Case report Phialophora verrucosa infection in a BMT patient TS Lundstrom, MR Fairfax, MC Dugan, JA Vazquez, PH Chandrasekar, E Abella and C Kasten-Sportes Detroit Medical Center, Wayne State University, Detroit, MI, USA Summary: Case report The patient was a 42-year-old Caucasian female diagnosed Phialophora is a dematiaceous fungus isolated from soil and wood. Human infections including chromoblasto- with AML (type M4) in February 1994 with 58% blasts on bone marrow biopsy. In March 1994 she received induction mycosis, mycotic keratitis, cutaneous infections, and prosthetic valve endocarditis have been reported. We therapy with idarubicin and cytarabine (Ara-C). Her course was complicated by Pseudomonas aeruginosa bacteremia report a case of fatal hemorrhage due to Phialophora verrucosa in a patient with prolonged neutropenia and Ludwig’s angina. Consolidation therapy in June 1994 with idarubicin and Ara-C was complicated by Stenotro- undergoing autologous bone marrow transplant (BMT) for acute myelogenous leukemia (AML). Bacterial infec- phomonas maltophilia sternal osteomyelitis which was treated for 6 weeks with intravenous broad-spectrum anti- tions complicated induction and consolidation chemo- therapies. Liposomal amphotericin B (LAMB) was biotics. In September 1994 the patient was in complete remission and hospitalized for autologous BMT. Prepara- given from day + 33 to day + 72 for febrile neutropenia. Death occurred on day + 74 due to tracheal hemorrhage. tive therapy consisted of busulfan and cyclosphosphamide. She received prophylactic norfloxacin and fluconazole. Autopsy revealed granulation tissue on the posterior wall of the trachea with fungal hyphae on histopathol- The BMT course was as follows: on day + 2, the patient developed neutropenia (absolute neutrophil count 500 ogy; the tissue grew Phialophora verrucosa. In vitro sus- ceptibility studies revealed a minimum inhibitory con- cells/mm 3 ). Shortly thereafter, she required total parenteral nutrition when severe mucositis developed. Between days centration to AmB of 0.1 g/ml. This represents the first reported case of invasive P. verrucosa in a BMT patient + 14 and + 19, the patient developed Clostridium ramosum and Enterococcus faecalis bacteremias requiring broad- leading to fatal hemorrhage, despite large cumulative doses of LAMB to which the organism remained spectrum antimicrobial therapy. Supraglottic edema requir- ing intubation and transfer to the intensive care unit susceptible. Keywords: Phialophora; fungus; chromoblastomycoses occurred on day + 25. At that time, indirect laryngoscopy revealed edema without focal lesions, felt to be secondary to chemotherapy-induced mucositis. An 8 day course of steroids was initiated. On day + 33 LAMB (liposomal Phialophora species are ubiquitous dematiaceous fungi that amphotericin B) (Abelcet, Liposome Company, Princeton, can be isolated from soil and wood. P. verrucosa is a well- NJ, USA) was begun empirically at a dose of 5 mg/kg/day known cause of chromoblastomycosis. Several species of for febrile neutropenia despite broad-spectrum antimicro- Phialophora have been reported to cause keratitis and bials. On day + 43 the patient required a tracheostomy for cutaneous infections, the majority of which occur following failure to wean from ventilatory support. In addition, oral traumatic inoculation. In addition, a case of prosthetic valve metronidazole was instituted for C. difficile enterocolitis. A endocarditis in a diabetic male has been described, with CAT scan of the thorax was performed in an attempt to associated fungemia. identify an occult infectious focus; this was negative. Back- We present a case of fatal tracheal hemorrhage due to up marrow was infused for failure to engraft. Finally, on invasive P. verrucosa, which, to our knowledge, represents day + 64, the patient’s absolute neutrophil count was above the first reported case causing infection in a BMT recipient. 500 cells/mm 3 (duration of neutropenia 65 days). Repeat laryngoscopy was done on day + 68. Findings included bilateral vocal cord paralysis with tracheal edema and ery- thema, and a black eschar at the site of impingement of the tracheal balloon, which was felt to be traumatic in nature. The following day the patient was again noted to be febrile Correspondence: Dr T Lundstrom, 4160 John R, Suite 2140, Wayne State and bacteremic with E. faecalis. On day + 72, LAMB was University, Detroit, MI 48201, USA discontinued after a cumulative dose of 14 782 mg. Two Presented in abstract form at Infectious Diseases Society of America, San days later the patient expired due to profuse tracheal Francisco, California, October 1995 Received 21 January 1997; accepted 30 June 1997 hemorrhage.