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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~ Acknowledgments
 ~  References
 ~  Article Figures

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  Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 33  |  Issue : 4  |  Page : 599-600
 

Unusual fungal sepsis of Alternaria alternata in acute lymphoblastic leukaemia in an adult patient


1 Department of Laboratory Medicine, Max Super Speciality Hospital, Patparganj, New Delhi, India
2 Institute of Laboratory Sciences, Max Super Speciality Hospital, Saket, New Delhi, India

Date of Submission18-Dec-2014
Date of Acceptance18-May-2015
Date of Web Publication16-Oct-2015

Correspondence Address:
S Jain
Department of Laboratory Medicine, Max Super Speciality Hospital, Patparganj, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.167324

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 ~ Abstract 

We report a case of unusual fungal sepsis of Alternaria alternata in a patient of acute lymphoblastic leukaemia in 62-year-old male who presented with complaints of 'off and on' fever with decreased oral intake. On evaluation, haemogram showed low platelet count and 68% blast cells in peripheral blood. On flow cytometry of peripheral blood, the gated blasts (approximately 55%) highly express CD45, CD10, CD19, CD22 and condition was diagnosed as acute lymphoblastic leukaemia. He was started on standard induction treatment along with supportive therapies. During the course of treatment, two sets of paired blood cultures were sent 48 h apart. All of blood cultures were done on Bac-T alert 3D system. All of them yielded fungus. The fungus was then grown on Sabouraud's Dextrose agar media. It was identified as A. alternata. The patient condition worsened and later had cardiac arrest in ICU and could not be revived.


Keywords: Acute lymphoblastic leukaemia, Alternaria alternata, fungal sepsis


How to cite this article:
Jain S, Tarai B, Tuli P, Das P. Unusual fungal sepsis of Alternaria alternata in acute lymphoblastic leukaemia in an adult patient. Indian J Med Microbiol 2015;33:599-600

How to cite this URL:
Jain S, Tarai B, Tuli P, Das P. Unusual fungal sepsis of Alternaria alternata in acute lymphoblastic leukaemia in an adult patient. Indian J Med Microbiol [serial online] 2015 [cited 2019 Nov 13];33:599-600. Available from: http://www.ijmm.org/text.asp?2015/33/4/599/167324





 ~ Introduction Top


Invasive fungal infection is among the leading causes of morbidity, mortality and economic burden for patients with acute leukaemia.[1] In the past few decades, the incidence of invasive fungal infections (IFIs) has increased dramatically. The certainty of diagnosis of IFIs is based on host factors, clinical evidence and microbiological examination.[2] The complexity of IFI in patients with leukaemia and the limitations of diagnostic tools require a strong clinical suspicion for early diagnosis. IFI management has been further complicated by Non-Aspergillus moulds. In addition even though the antifungal armamentarium has expanded rapidly, the associated motility remains high.


 ~ Case Report Top


Here, we report a case of rare Invasive fungal sepsis by Alternaria alternata in a patient of acute lymphoblastic leukaemia. A 62-year-old male, who presented with complains of fever off and on with poor oral intake, decreased urine output and generalised weakness.

At admission, on examination, he was conscious orientated, responding to verbal commands, febrile, PR - 132/min, SPO2-100%, BP - 100/70 mm, RR - 34.

On investigations

The total haemogram - Hb-8.6gm/dl, PCV-24.3%, TLC-1.2/l, RBC count-2.9/L, platelet-0.9/L, RDW-17.9. Peripheral blood had 68% blasts cells. His liver and renal parameters were normal. X-ray chest showed ill-defined right mid lower zone opacity diffuse haze in right lung. HRCT (thorax) showed few fibro-parenchymal lesions in B/L upper lobe, B/L pleural effusion seen with collapse consolidation of underlying lung parenchyma. Multiple mildly enlarged paratracheal and pre-tracheal nodes were seen. CECT upper abdomen - liver shows diffuse reduction in parenchymal attenuation with fatty infiltrates of hepatic parenchyma, subtle focal hypodense lesions in segment of VI/VIII of liver with leukaemic deposits.

Flow cytometry was performed on the 2nd day of admission, the peripheral blood was done which showed gated blasts (approximately 55%) highly express CD45, CD10, CD19, CD22, condition was diagnosed as acute lymphoblastic leukaemia. He was started on standard induction treatment along with supportive therapies. Blood and platelets were transfused as needed. Initially, his general condition in post chemotherapy period was stable but after 2 weeks of therapy, he developed tachypnoea and fever. Initially, he was managed on BiPAP but as the O2 requirement increased; he was shifted to MICU and intubated. The patient condition worsened and later had cardiac arrest in ICU and patient could not be revived.

Microbiological evidence

During the course of treatment, two sets of paired blood culture were sent on 20th and 22nd day of admission. All the blood cultures were incubated in BacT Alert 3D system. The fungus was grown Sabouraud's Dextrose Agar media. For species identification, it was sent to Department of Mycology, PGI, Chandigarh.

The identification was confirmed as A. alternata. The identification of Alternaria isolate was exclusively on the basis of morphological criteria - being the morphology of the conida and the formation of condial chains.


 ~ Discussion Top


Alternaria is a dematiaceous hyphomycete that is frequently involved in human infection.[3]Alternaria can also be found on normal human and animal skin and conjunctiva.[4] This fungus has been associated frequently with several different types of human infections, e.g. Sino bronchial disease, paranasal sinusitis, ocular infections, onychomycosis, Cutaneous and subcutaneous infections, and, more rarely, granulomatous pulmonary disease, soft palate perforation and disseminated disease.[5] IFI by alternaria is very rare with only a few published case reports.

Prolonged severe neutropenia (<0.5 × 109), corticosteroids, broad spectrum antibiotics and indwelling intravenous catheters are all important risk factors for the development of disseminated fungal infection. The demonstration of a fungal element or positive culture from a site, in addition to pathological of and clinical evidence of tissue damage establishes fungal infection. Blood culture has very poor sensitivity for detecting moulds. The presence of mould in urine or respiratory tract specimen could simply reflect the presence of contaminants or colonisation. However, a positive culture is considered significance for invasive mycosis in the presence of related clinical signs and symptoms compatible with relevant organisms [Figure 1].
Figure 1: Microscopic morphology of Alternaria. The Alternaria conida are golden brown, frequently tapering gradually into a beak that is up to half the length of the conidium and occur commonly in unbranched chains three to five conidia

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Alternaria is worldwide with many species being common saprophytes in soil, air and variety of other habitats.[6] There is no case report of A. alternata infection from blood culture till date. This is the first case report of disseminated A. alternata infection in acute lymphoblastic leukemia patient.

Cases of Alternaria have responded well to the treatment with the older antifungal drugs, e.g., amphotercin B, flucytosine, flucytosine, fluconzole, miconazole and nystatin.[7]

Trends in fungal infection are rapidly changing and novel diagnostic and therapeutic options are emerging. However, several areas in IFI management require further exploration risk stratification based on immogenic factors, the role of new diagnostic modalities, prediction models for differentiating diverse fungal infections and pre-emptive versus empirical therapy.[7],[8] In order to optimise our diagnostic and therapeutic management of IFI in patients with acute leukaemia, further basic research and clinical trials are desperately needed.


 ~ Acknowledgments Top


We acknowledge here the support and efforts of Department of Mycology, PGI Chandigarh in helping us to recognise the fungus A. alternata for our case report.

 
 ~ References Top

1.
Pastor FJ, Guarro J. Alternaria infections: Laboratory diagnosis and relevant clinical features. Clin Microbiol Infect 2008;14:734-46.  Back to cited text no. 1
    
2.
Bow EJ. Considerations in the approach to invasive fungal infection in patients with haematological malignancies. Br J Haematol 2008;140:133-52.  Back to cited text no. 2
    
3.
Chamilos G, Luna M, Lewis RE, Bodey GP, Chemaly R, Tarrand JJ, et al. Invasive fungal infections in patients with hematologic malignancies in a tertiary care cancer center: An autopsy study over a 15-year period (1989-2003). Haematologica 2006;91:986-9.  Back to cited text no. 3
    
4.
Leventakos K, Lewis RE, Kontoyiannis DP. Fungal infections in leukemia patients: How do we prevent and treat them? Clin Infect Dis 2010;50:405-15.  Back to cited text no. 4
    
5.
Gilaberte M, Bartralot R, Torres JM, Reus FS, Rodríguez V, Alomar A, et al. Cutaneous alternariosis in transplant recipients: Clinicopathologic review of 9 cases. J Am Acad Dermatol 2005;52:653-9.  Back to cited text no. 5
    
6.
Mårdh PA, Hallberg T. Alternaria alternata as a cause of opportunistic fungal infections in man. Scand J Infect Dis Suppl 1978;16:36-40.  Back to cited text no. 6
    
7.
Austen B, McCarthy H, Wilkins B, Smith A, Duncombe A. Fatal disseminated fusarium infection in acute lymphoblastic leukaemia in complete remission. J Clin Pathol 2001;54:488-90.  Back to cited text no. 7
    
8.
Lerner LH, Lerner EA, Bello YM. Co-existence of cutaneous and presumptive pulmonary alternariosis. Int J Dermatol 1997;36:285-8.  Back to cited text no. 8
    


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