Unknown

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Unknown 116
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Case Presentation

• 44 year-old male with recently diagnosed acute
  myelogenous leukemia, s/p 5 cycles of
  chemotherapy
• During the 5th cycle he developed profound
  neutropenia
• 5 days ago he was admitted with neutropenic
  fever, no source found
• Started on imipenem/cilastin
• G-CSF therapy begun

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• Hospital day 4 Neutropenia resolved but patient
  remained febrile intermittently
• Hospital day 5 You are consulted.
• Vitals T39.3 BP 105/65 P 105 R18
• Exam
• Patient looks well, feels a little nauseous
• Mild RUQ tenderness to palpation
• Otherwise unremarkable

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LABS

• WBC 6500 (50 Neutrophils, 5 bands, 35
  lymphocytes
• Hct 35 Albumin 2.8
• Platelets 110,000 TP 6.4
• AST/ALT 41/43 D. Bili 0.8
• Alk Phos 380 T Bili 1.1
• Chem 10 within normal limits

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Abdominal CT

• Multiple hypodense lesions in the liver and
  spleen

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Question

• What is your diagnosis?

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Answer
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Answer

• Hepatosplenic Candidiasis

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Hepatosplenic Candidiasis

• AKA chronic disseminated candidiasis
• Complication of chemotherapy, after prolonged,
  intense neutropenia
• Disseminated infection presenting as focal
  hepatic, splenic, and rarely kidney lesions

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• Gastrointestinal mucosal damage secondary to
  intensive chemotherapy may allow colonization
  with Candida species and subsequent seeding of
  the portal vein
• Broad spectrum abx may promote fungal growth

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• Seen less frequently because of the widespread
  use of fluconazole or other antifungal agents for
  prophylaxis in high-risk leukemic and stem cell
  transplant populations
• Almost always C. albicans, rarely C. tropicalis,
  C. parapsilosis, C. glabrata, and C. krusei

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Diagnosis

• Diagnosis is often difficult
• Most often persistent or recurrent fever in a
  patient who has recently received broad spectrum
  antibiotics for neutropenic fever, but whose
  neutrophil counts have now recovered
• Right upper quadrant pain, nausea
• Elevated alkaline phosphatase

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Diagnosis

• Ultrasound may reveal multi-layered bullseye
  lesions
• CT multiple lucencies, some of which can become
  quite large, in liver, spleen, and less often in
  kidneys
• Blood cultures often show no growth
• Liver biopsy(rarely needed) multiple
  well-circumscribed micro abscesses containing
  neutrophils and organisms that suggest Candida
  species

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Treatment

• IDSA Guidelines
• Fluconazole 6 mg/kg/d in stable patients
• Ampho B 0.6-0.7 mg/kg/d or liposomal (3-5
  mg/kg/d) in acutely ill or refractory disease
• Consider 1-2 week of induction with ampho B
  followed by prolonged fluconazole
• Continue therapy until calcification or
  resolution of lesions
• Patients on treatment may continue to receive
  chemotherapy