Risk of reactivation of a recent invasive fungal infection in patients with hematological malignancies undergoing further intensive chemo-radiotherapy. A single-center experience and review of the literature.
BACKGROUND
Patients with hematologic malignancies and a history of an invasive fungal infection are considered to be at high risk of suffering reactivation of the infection during subsequent intensive chemotherapy.


METHODS
From January 1993 to September 1996, nine patients with a hematologic malignancy and previous invasive pulmonary aspergillosis (IPA) or Pseudallescheria boydii pneumonia and five with invasive candidiasis received further intensive chemotherapy (n = 3) or a bone marrow or peripheral blood stem cell transplant (n = 11) four days to 13 months (median three months) from the start of therapy for the fungal infection. Five patients with IPA and all five with invasive candidiasis showed complete or good partial radiologic resolution of the infection with the primary antifungal therapy given, which was continued before, during and after the period(s) of subsequent neutropenia.


RESULTS
Twelve of the 14 patients showed no signs of progression or reactivation of the fungal infection during therapy, while two patients with active IPA died with progressive aspergillosis shortly after an allogeneic transplant. A review of the literature revealed that in both types of infections the risk of reactivation and dissemination appears low after achieving clinical and radiologic signs of response, which takes several weeks or months before proceeding to further antileukemic therapy.


CONCLUSIONS
Despite lack of definite evidence, administration of an active antifungal drug before, during and after the period of neutropenia appears to be useful. In IPA, residual masses, nodules or cavities in the lung usually contain viable invasive fungal elements and should be resected whenever possible. On the other hand, the risk of reactivation and progression of an active fungal infection during intensive chemoradiotherapy is very high, and novel therapeutic strategies appear warranted in this setting.
Martino
R
R
Unitat d'Hematología Clinica, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
Lopez
R
R
Sureda
A
A
Brunet
S
S
Domingo-Albós
A
A
D000293:Adolescent; D000328:Adult; D000368:Aged; D000666:Amphotericin B / Q000008:administration & dosage / Q000627:therapeutic use; D000741:Anemia, Aplastic / Q000150:complications / Q000188:drug therapy / Q000628:therapy; D000935:Antifungal Agents / Q000008:administration & dosage / Q000627:therapeutic use; D000970:Antineoplastic Agents / Q000009:adverse effects* / Q000627:therapeutic use; D001228:Aspergillosis / Q000150:complications / Q000401:mortality; D016026:Bone Marrow Transplantation; D002177:Candidiasis / Q000150:complications / Q000401:mortality; D018450:Disease Progression; D005260:Female; D015725:Fluconazole / Q000008:administration & dosage / Q000627:therapeutic use; D019337:Hematologic Neoplasms / Q000150:complications* / Q000188:drug therapy / Q000401:mortality / Q000532:radiotherapy / Q000628:therapy; D018380:Hematopoietic Stem Cell Transplantation; D006801:Humans; D016867:Immunocompromised Host; D017964:Itraconazole / Q000008:administration & dosage / Q000627:therapeutic use; D008172:Lung Diseases, Fungal / Q000150:complications / Q000401:mortality; D008297:Male; D008875:Middle Aged; D008271:Mycetoma / Q000150:complications / Q000401:mortality; D009181:Mycoses / Q000150:complications* / Q000401:mortality / Q000517:prevention & control; D009503:Neutropenia / Q000139:chemically induced / Q000150:complications; D011292:Premedication; D011446:Prospective Studies; D011541:Pseudallescheria; D011878:Radiotherapy / Q000009:adverse effects*; D012008:Recurrence; D016896:Treatment Outcome
D000935:Antifungal Agents; D000970:Antineoplastic Agents; D017964:Itraconazole; D000666:Amphotericin B; D015725:Fluconazole