Discussion
Simultaneous dual invasive mold infections is exemplified by a rare condition, even in profoundly immunocompromised hosts, evolving to disseminating progression and poor outcome (12).
Here we report the case of the concurrent sino-pulmonary aspergillosis and mucormycosis infection complicating a leukemic 21-year-old man clinical course with severe prolonged neutropenia induced by the initial induction chemotherapy regimen as a significant risk factor .
Multidisciplinary correlation of radiological, histological, microbiological, and serological findings is critical for making a definite diagnosis and improving outcome in high risk patients.
Recent data associating to the diagnosis of fungal pneumonia in adults indicates that a high-resolution CT scan (HRCT) is the preferred radiological method regarding to it’s sensitivity and availablity. Among neutropenic patients with invasive pulmonary aspergillosis, nodules or oapcities with a “halo sign” remain practical indicators (13). Likewise, CT scans confirm sinus involvement and lesion severity, signifying the presence of fungal sinus infection (14).
A tissue diagnosis can be achieved through an appropriate biopsy, which identifies the characteristic invasive hyphae, positive culture, or both. Initially, the culture of the affected tissue may yield negative results, making histopathologic examination necessary for early detection (15).
PCR methods sufficiently provide a prompt diagnostic test for IFIs that is performable on whole blood, serum, plasma, and BAL fluid (16). Furthermore, PCR is directly capable of specifying mutations linked to drug resistance and monitoring treatment progress an is linked to improved survival rates when treatment initiation results in negativity (17).
Distinct assays considering different thresholds were adopted forAspergillus galactomannan (GM) antigen (18).
The European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria for invasive aspergillosis and mucormycosis are appropriate for hematologic malignancy patients, and our patient was considered to have probable IPA based on an abnormal CT scan of the lungs and BAL GM results, probable AIFR due to aspergillosis based on positive culture, confirmed AIFR due to mucormycosis based on pathology and probable pulmonary mucormycosis based on positive BAL culture (19). The European Confederation of Medical Mycology (ECMM) and the European Conference on Infections in Leukemia (ECIL) guidelines recommend first-line mold active antifungal therapy combined with surgery and control of underlying conditions. While voriconazole are the agent of choice for the management of IPA, They both firmly support liposomal amphotericin B (L-AmB) as a mucormycosis first-line treatment in adults (20,21).
Also, some previous reports noted that invasive pulmonary Aspergillus and Mucor coinfections were countered sufficiently using high doses of liposomal AmB alone (22).
The administration of liposomal amphotericin B, in comparison to other amphotericin B formulations, has been found to have significantly lower occurrence rates of probable side effects, including nephrotoxicity and, infusion-related reactions (fever and rigors), as well as hypokalaemia (23).
It is recommended initial empirical therapy for possible invasive mold infection regarding to its broad spectrum of activity considering local epidemiological prevalence of pathogens. Patients who received the highest dose regimens tended to have a greatest rate of cure, despite more frequent renal adverse effects (24). To date combination treatment of antifungals is not recommended as a first‐line therapy due to their no significant reduction trend in mortality rate and is conserved for patients who are refractory to standard regimen or unable to tolerate high dose of L-AmB adverse effects (25).
Even though the treatment options for patients with HMs remain relatively restricted, this patient survived because of an early diagnosis and prompt treatment.