A 66-year-old man presented with fatigue and fever. He was in excellent health status, with no comorbidity, working as a gamekeeper. Blood count revealed 80 G/L leukocytes, 84% blasts, hemoglobin 10.5 g/dL and platelets 27 G/L. He was hospitalized in intensive care unit (ICU) because of oxygen requirement and acute renal failure due to tumor lysis syndrome. Acute myeloid leukemia (AML-5b) with complexe karyotype was diagnosed on bone marrow examination. After initial cytoreduction with Hydroxyurea and Dexamethasone, intensive chemotherapy (Idarubicine and Cytarabine) was initiated in the ICU under close monitoring. Extra-renal epuration was required for tumor lysis syndrome.
Because of fever at admission, Tazocilline was initiated. A few days later, CT-scan revealed multiple bilateral pulmonary nodular lesions, suggesting invasive aspergillosis. Voriconazole was started and antibiotics enlarged to carbapenems. Fever persisted at 40° and patient became confused. CT-scan highlighted worsened pulmonary lesions with ground glass opacities and condensations, neutropenic enterocolitis, and a small meningeal haemorrhage. Four days later, neurological status worsened. Cerebral CT-scan revealed multiple bilateral disseminated cortical nodular lesions. Cerebral MRI confirmed an acute cerebritis with multiple lesions without necrosis (Fig. 1). Patient required mechanical ventilation because of acute respiratory failure. In parallel, patient developed erythematous nodular cutaneous lesions, on limbs, chest, face and neck. Extensive infectious work-up was performed in blood, bronchoalveolar lavage, cerebrospinal fluid and skin biopsy to rule out bacterial pathogens, viruses, aspergillosis, mucormycosis, nocardia, leishmania, cryptococcus, fusarium, toxoplasmosis. β D1,3-glucanes were positive in bronchoalveolar lavage (110 pg/mL). Blood cultures identified Klebsiella oxytoca bacteremia. Skin biopsy analysis showed multiple fungal filaments (Figs. 2, 3, 4), culture identifying Scedosporium apiospermum, resistant to Amphotericine and Posaconazole and intermediate to Izavuconazole. Under broad-spectrum antiobiotics and antifungals, fever persisted with biological markers of hemophagocytic lymphohistiocytosis. Unfortunately, patient died of cerebral oedema.
Invasive fungal infections remain a serious complication in hematology patients. Rare pathogens are a diagnostic and therapeutic challenge, with numerous differential diagnosis. Considering the early occurrence of infection, prior colonization was probable, potentially favored by patient activity.