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.