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Early fatal Rhizopus infection on voriconazole prophylaxis following allogeneic stem cell transplantation

Bone Marrow Transplantation volume 39, pages 807–808 (2007)Cite this article

We read the article by Trifilio et al.1 with great interest. In that article, 58 patients were identified with zygomycosis. Of these 58 patients, 56 received voriconazole as primary or secondary prophylaxis. Invasive fungal infections, particularly Aspergillus, are one of the leading causes of death in patients undergoing allogeneic stem cell transplantation (alloSCT). Both voriconazole and caspofungin have been shown to be effective antifungal agents against aspergillosis.2 For this reason, in addition to the increasing prevalence of fluconazole-resistant Candida glabrata and Candida krusei, many haematopoietic stem cell transplant recipients are receiving voriconazole for fungal prophylaxis.

We present here a 54-year-old male patient who was found to be severely pancytopenic in May 2006. The patient was diagnosed with myelodysplastic syndrome and was treated with 400 mg thalidomide daily. The patient received 200 mg voriconazole b.i.d., for fungal prophylaxis. In September 2006, his chest X-ray was normal while still being neutropenic. In October 2006, the patient underwent myeloablative alloSCT from a HLA-identical sibling. On day −4 the patient developed febrile neutropenia. A chest X-ray showed bilateral airspace disease with pleural effusion. Empirical antibacterial treatment was started. Caspofungin (70 mg on day 1, then 50 mg daily) was added to voriconazole. The patient was intubated because of respiratory and liver failure on day +2. Defibrotide was initiated for probable veno occlusive disease (VOD) of the liver. Bronchoalveolar lavage (BAL) and diagnostic thoracentesis were performed on day +7. Fungal elements, Pneumocystis carinii, or bacteria were not detected by microscopic evaluation. The patient died on day +9 because of multi-organ failure when all cultures were negative. One month later, Rhizopus spp. were isolated only after broth enrichment in the pleural fluid (identification was carried out by DNA sequencing at the Laboratory of Medicine and Pathology at Mayo Clinic, Rochester, MN, USA). At the same time, the sputum culture also grew Rhizomucor spp.

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Authors and Affiliations

  1. Department of Medicine, Section of Hematology/Oncology, Medical College of Georgia, Augusta, GA, USA

    C Ustun, S Farrow, H Fain & A P Jillella

  2. University of Georgia College of Pharmacy, Augusta, GA, USA

    D DeRemer & H Fain

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  1. C Ustun
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  2. S Farrow
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  3. D DeRemer
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Correspondence to C Ustun.

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Ustun, C., Farrow, S., DeRemer, D. et al. Early fatal Rhizopus infection on voriconazole prophylaxis following allogeneic stem cell transplantation. Bone Marrow Transplant 39, 807–808 (2007). https://doi.org/10.1038/sj.bmt.1705679

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