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Atypical Presentation of Scedosporium Pneumonia

Atypical Presentation of Scedosporium Pneumonia. Gabriel Johnson, DO Leslie Spikes, MD Department of Internal Medicine University of Kansas Medical Center Kansas City, KS. Introduction. Provide a brief overview of scedosporium epidemiology

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Atypical Presentation of Scedosporium Pneumonia

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  1. Atypical Presentation of Scedosporium Pneumonia Gabriel Johnson, DO Leslie Spikes, MD Department of Internal Medicine University of Kansas Medical Center Kansas City, KS

  2. Introduction • Provide a brief overview of scedosporium epidemiology • Present an unusual case of a life-threatening Scedosporium infection in a patient without typical risk factors for fungemia • Identify diagnostic and therapeutic challenges

  3. Scedosporium Infections in Humans • Localized infections: • Bronchiectatic lungs • Mycetomas • Disseminated infections: • Transplant wards • Up to 10% of cystic fibrosis patients colonized in transplant wards • Near drowning events • Rarely in the immuno-competent Cortez et. Al. Infections Caused by Scedosporium spp. Clin Microbiol Rev. 2008 January; 21(1): 157–197.

  4. Complication of organ transplant • Study of 80 cases of scedosporium infection in transplant patients at 5 academic institutions • 23 hematopoietic stem cell transplants • 57 solid organ transplants • Disseminated infection • 2 noncontiguous organs or + blood culture • 69% of HSCT with scedosporium • 53% of SOT with scedosporium Husein et. al. Infections due to Scedosporium in Transplant Recipients: Clinical Characteristics. Clinical Infectious Disease 2005 Jan 1;40

  5. Scedosporium - overview • Ubiquitous white mold • Tolerates aerobic and anaerobic conditions and wide range of temperature and osmolarity • Transmission • Direct inoculation (mycetoma) • Inhalation of airborne particles Williamson et. al. Genetic Epidemiogy of Scedosporium in Patients with Chronic Lung Disease. J Clin Microbiol. 2001 January; 39(1): 47–50.

  6. Species • Scedosporium apiospermum • Typically sensitive to multi-agent antifungal therapy • Voriconazole associated with survival improvement over amphotericin • Scedosporium prolificans • Treatment generally requires immunosuppression reversal and surgical intervention. Cortez et. Al. Infections Caused by Scedosporium spp. Clin Microbiol Rev. 2008 January; 21(1): 157–197.

  7. American Society for Microbiology: Clinical Microbiology Reviews

  8. Infection sites 2000-2007 Cortez et. Al. Infections Caused by Scedosporium spp. Clin Microbiol Rev. 2008 January; 21(1): 157–197.

  9. Case Report • A 72 year old woman presented to ER • 3 months of progressive hemoptysis • Diffuse pulmonary nodules on recent imaging • 5 days of fever, chills, and myalgias

  10. Past Medical History • Pulmonary arterial hypertension • Diagnosed 2 years prior • Likely secondary to chronic pulmonary emboli • On continuous infusion intravenous treprostinil • On warfarin for chronic thromboemboli • Breast cancer • Right mastectomy and radiation 8 years prior • No history of atypical or recurrent infections

  11. Recent Medical History • CT guided needle biopsy of pulmonary nodule had been performed 3 weeks prior • Histology: necrotic tissue, peribronchial fibrosis and chronic inflammatory changes without granulomas • Gram stain/culture: no bacterial or fungal growth • Cytology: no malignant cells

  12. Social History • Independently performs activities of daily living • 25 pack years but quit 2 years prior • No occupational or environmental exposures

  13. Physical Exam T 36.7 BP 121/70 P 99 R 24 Pulse ox: 95% on room air HEENT – Unremarkable Chest – right sided indwelling Hickman catheter Heart – Unremarkable Lungs Diminished breath sounds bilaterally, no rales, rhonchi, or wheezing Abdomen: Unremarkable Extremities/Skin: Unremarkable

  14. Laboratory Data • Fungitell:257 (41 previously) [Normal < 40] • Blood Culture: Scedosporium elements

  15. 3 weeks prior

  16. Hospital Course • Sudden hemoptysis of 600 ml frank blood • Resolved with reversal of anticoagulation • Bronchoscopy with lavage performed • Hemorrhagic fluid with negative cultures • Repeat CT guided biopsy of left lobe nodule • Pathologic findings unchanged and unremarkable • Hickman catheter removed • No fungal or bacterial growth on tip culture

  17. Hospital Course • Amphotericin and voriconazole initiated • Repeat CT 2 weeks later showed progression • Patient requested to discontinue all IV medications and go home with home health care • Oral voriconazole and terbinafine • Oral sildenafil • New 2 L oxygen requirement

  18. Speciation and Sensitivity • Speciation: ScedosporiumApiospermum • Sensitivity testing: • Amphotericin R • Caspofungin R • Micafungin S • Voriconazole S • Itraconazole S • Posaconazole S

  19. Resolution • Patient’s hypoxia improved and she was able to titrate off oxygen • No recurrence of fever or hemoptysis • She completed 6 months of antifungal therapy with voriconazole and terbinafine

  20. Radiographic regression 4 months later

  21. Case Summary • Atypical presentation of a rare fungal pathogen • Diagnostic difficulties • Voriconazole as preferred agent • Questioning her risk factors

  22. Acknowledgments Dr. Leslie Spikes Associate Professor of Internal Medicine University of Kansas Medical Center

  23. European Society for Imunodeficiencies DeVries et.al. Clinical & Experimental Immunology vol. 145, iss. 2. pages 204–214, August 2006

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