Letter to the Editor: Fungal Infection From Fusarium spp. in Children WithRefractory Hematologic Malignancies

To the Editor: We read with interest the report aboutfungal infection fromFusarium in children with refrac-tory hematologic malignancies by Mangini and de Ca-margo (1). However, we wish to comment on the type,dosage and duration of the treatment with amphoteri-cin-B (Ampho-B) used by Mangini and de Camargo. Webelieve that, if there are any suspicious lesions observedin chest or abdominal CT scans or if there is persistentfever in patients with hematologic malignancies, doses ofAmpho-B should be gradually increased (4–8 mg/kg/day). Owing to dose-limiting renal side effects of con-ventional Ampho-B (>1 mg/kg/day), liposomal (L-Ampho-B) or lipid complex forms (LC-Ampho-B) of thedrug should be substituted when such high doses arerequried (2–4).

We had a similar case of invasiveFusariumspp. in-fection in a child with AML following high doses ofcytarabine (total 24 g in 9 days). It has been used asintensification therapy (according to the CCG 2961 AMLprotocol). The patient developed severe neutropenia(<100 neutrophils/ml) and fever of unknown origin 2days after the termination of chemotherapy.

Antibacterial (ceftazidime, amikasin, and vancomy-cin) and antifungal (L-Ampho-B, 1 mg/kg/day) therapieswere started concomitant with febrile neutropenia. Chestand abdominal CT scans were taken on day 14 that re-vealed pulmonary and hepatic hypodense areas indicat-ing fungal involvement of these organs. Thus, the dose ofL-Ampho-B was gradually increased, i.e., 1 mg/kg/dayevery 2 days, until a maximum dose of 4 mg/kg wasattained. Eventually the patient became afebrile. On day16, the microbiology department reported that all bloodcultures from peripheral veins and central venous cath-eters were positive forFusariumspp. Therefore, the cen-tral nervous catheter was removed. Her response andtolerance to high doses of L-Ampho-B were found to besatisfactory. Hypokalemia was the only side effect of thehigh-dose L-Ampho-B, which was handled easily by in-travenous administration of potassium. On completion of14 days of 4 mg/kg/day L-Ampho-B, the dose was ta-

pered to 1 mg/kg/day, which was maintained for another2 months. Five months later, on her last visit, she wasdoing well without any complication or relapse of theinfection.

Additional clinical experience is required to establishthe most effective dosage, and duration of treatment withL-Ampho-B in patients with invasive fungal infectionsfrom Fusariumspp.

Nurdan Tac¸yıldız, MD

Gulsan Yavuz,MD

Emel Unal, MD

Department of Pediatric OncologyAnkara University Medical School

Ankara, Turkey

Sevgi Gozdasog˘lu, MD

Mehmet Ertem,MD

Departments of Pediatrics and HematologyAnkara University Medical School

Ankara, Turkey

Derya Aysev,MD

Department of Pediatric MicrobiologyAnkara University Medical School

Ankara, Turkey

REFERENCES

1. Mangini C, de Camargo B. Fungal infection due toFusarium(spp.) in children with refractory hematologic malignancies. MedPediatr Oncol 1999;32:149–150.

2. Segal BH, Walsh TJ, Liu JM, et al. Invasive infection withFu-sarium chlamydosporumin a patient with aplastic anemia. J ClinMicrobiol 1998;6:1772–1776.

3. Arney KL, Tiernan R, Judson MA. Primary pulmonary involve-ment of Fusarium soloniin a lung transplant recipient. Chest1997;112:1128–1130.

4. Mahlkenecht U, Linding FV, Mertelsman R. Successful treatmentof disseminated central nervous aspergillosis in a patient withacute myeloblastic leukemia. Leuk Lymphoma 1997;27:191–194.

Medical and Pediatric Oncology 33:596 (1999)

© 1999 Wiley-Liss, Inc.