A rare case of disseminated scedosporium presenting with angioinvasive lung nodule in a newly diagnosed cancer patient

SESSION TITLE: Extra-pulmonary and Extra-ordinary Infections SESSION TYPE: Case Reports PRESENTED ON: 10/09/2023 01:00 pm - 02:00 pm INTRODUCTION: Scedosprium is an opportunistic fungus causing infection with varying presentations in patients. Its prevalence is increasing due to increased use of antineoplastics, immunosuppressants, corticosteroids and its unpredictable antifungal resistance. Here we discuss a case of an Acute Myeloid Leukemia (AML) patient who rapidly developed disseminated Scedosporium. CASE PRESENTATION: A 24 year old female presented to an outside hospital with fatigue and vaginal bleeding. Labs were remarkable for pancytopenia with myeloblasts. She was diagnosed with AML and failed induction therapy twice never reaching remission with development of febrile neutropenia. Her clinical work up revealed a 2.5cm right upper lung nodule for which she underwent percutaneous fine needle aspiration which showed angioinvasive fungal elements. Fungal PCR confirmed Scedosporium apiospermum. She was initiated on isavuconazole and salvage therapy for AML. Follow up CT was concerning for infectious spread given increased lung nodules with new liver and splenic lesions. She was broadened to amphotericin and transferred to our hospital. Repeat imaging showed a growing RUL mass (4.2 x 3.3 cm). She also developed a right upper extremity nodule and underwent punch biopsy which confirmed the diagnosis of disseminated Scedosporium apiospermum. Voriconazole was initiated in addition to amphotericin and later terbinafine. After her neutrophil counts recovered, she transitioned to monotherapy with isavuconazole due to rising liver function studies. She remained on monotherapy with stable imaging over the period of two years. She then underwent haploid stem cell transplant and sixteen days post transplant and pre engraftment, a CT chest showed increased known right lung mass (5.1 x 4.0 cm). A robotic bronchoscopy with transbronchial biopsy again revealed Scedosporium boydii (teleomorph of scedosporium apiospermum). The findings suggested recrudescence of her fungal infection for which she was started back on dual therapy with isavuconazole and amphotericin. One month later, improvement was noted on imaging. She was restarted on monotherapy with voriconazole given previous breakthrough infection on isavuconazole. DISCUSSION: Scedosporium is a newly emerging pathogen seen in AML patients due to low susceptibility to most antifungal treatments. Voriconazole is considered the ideal treatment. In this case, when the patient was neutropenic, she required combined therapy with amphotericin and isavuconazole or voriconazole to achieve improvement and containment of her fungal infection. She was only able to continue monotherapy when neutrophil counts normalized, demonstrating that host immunity is vital for infection control. In this case, sampling and monitoring her pulmonary nodule was the first step in the diagnosing her fungal infection and later used guide treatment and monitor treatment response. CONCLUSIONS: Providers managing patients with AML and pulmonary nodules should be aware of invasive fungal infections, particularly Scedosporium. Scedosporium carries high mortality rates with little evidence to guide antifungal therapy. One study noted neutropenia, dissemination, and lack of antifungal therapy was associated with 3-month mortality. Voriconazole is currently the treatment of choice; however, isavuconazole has been shown to be just as effective. In addition, when monotherapy alone is not successful, combined therapy with amphotericin can result in improvements. Monitoring patient's symptoms in addition pulmonary nodule size can guide treatment and treatment responses. REFERENCE #1: Jain P, Nagarajan P, Prayag P, Benton CB, Kadia T, Groisberg R, Kontoyiannis DP, Mulanovich VE, Pemmaraju N. Mixed angioinvasive exserohilum and scedosporium infection in a patient with AML. Am J Hematol. 2017 Jan;92(1):119-120. doi: 10.1002/ajh.24455. Epub 2016 Jul 14. PMID: 27341684; PMCID: PMC5884637. REFERENCE #2: Rollin-Pinheiro R, Xisto MIDdS, de Castro-Almeida Y, Rochetti VP, Borba-Santos LP, Fontes YdS, et al. (2023) Pandemic Response Box® library as a source of antifungal drugs against Scedosporium and Lomentospora species. PLoS ONE 18(2): e0280964. REFERENCE #3: Bronnimann D, Garcia-Hermoso D, Dromer F, Lanternier F; French Mycoses Study Group; Characterization of the isolates at the NRCMA. Scedosporiosis/lomentosporiosis observational study (SOS): Clinical significance of Scedosporium species identification. Med Mycol. 2021 May 4;59(5):486-497. doi: 10.1093/mmy/myaa086. PMID: 33037432. DISCLOSURES: No relevant relationships by Chelsea Dwyer Speaker/Speaker's Bureau relationship with Intuitive Surgical Please note: 04/2022-present Added 03/31/2023 by Bryan Husta, source=Web Response, value=Consulting fee No relevant relationships by Diana Song No relevant relationships by David Wisa