Chronic disseminated candidiasis in patients with hematologic malignancies. Clinical features and outcome of 29 episodes.
OBJECTIVE
To evaluate the characteristics of patients affected by hematologic malignancies who developed a chronic disseminated candidiasis (CDC), and to ascertain the factors that influenced the outcome, in a retrospective study conducted between January 1990 and December 2000, in 4 Hematology Divisions.


METHODS
CDC was diagnosed by clinical features combined with radiological and/or histologic and/or microbiological data.


RESULTS
Twenty-eight patients (male/female 14/14; average age 42 years, range 12-67) developed a CDC. Twenty had acute myeloid leukemia, 5 had acute lymphocytic leukemia and 3 had non-Hodgkin's lymphoma. All patients received chemotherapy, including cytarabine for 21 of them (75%). Before the infection, 22 patients (79%) were neutropenic (absolute neutrophil count < 0.5 x 10(9)/L) for an average of 20 days (8-36), but at CDC diagnosis only 3 patients (11%) were neutropenic. Twenty-two patients (75%) received antifungal prophylaxis for an average of 15 days (10-60). Before diagnosis of CDC, 9 patients (32%) had a candidemia. The sites compromised by CDC were: liver in 27 patients (96%) and/or spleen in 11 patients (38%). Ten patients had other organs involved: lung in 6 patients (21%), kidney in 4 patients (14%), other sites 2 patients (7%). Abdominal ultrasonography was positive in 96% of patients (27/28), and abdominal computed tomography-scan was positive in 100% of cases in which it was performed (21/21). Liver biopsy was positive in 10/15 patients (67%). The main signs and symptoms were: fever 86%, abdominal pain 54%, diarrhea 32%, tenderness 25%, vomiting 25%, jaundice 29%, dysphagia 7%. Among chemical analyses, the most sensitive test was alkaline phosphatase, with a 3-5-fold increase in 24 patients (86%); an increase of liver transaminases and g-glutamyl transferase was observed in less than 50% of patients. By 30 days after diagnosis 4 patients had died, 1 from infection, and 3 progression of the hematologic malignancy without signs of active CDC. Within 3 months from diagnosis 14 out of the remaining 24 patients (58%) received further chemotherapy: in particular, 2 patients underwent transplantation procedures.


CONCLUSIONS
In our experience CDC is not a fatal complication of patients with hematologic malignancy, on the contrary to that observed for other fungal infections (i.e. aspergillosis, candidemia), characterized by a higher mortality rate. The major problem of this fungal complication is correlated to the delay in the following treatment for the hematologic malignancy with a high risk of progression of malignancy.
Pagano
Livio
L
Department of Hematology, Catholic University, largo Francesco Vito 1, 00168 Rome, Italy. lpagano@rm.unicatt.it
Mele
Luca
L
Fianchi
Luana
L
Melillo
Lorella
L
Martino
Bruno
B
D'Antonio
Domenico
D
Tosti
Maria Elena
ME
Posteraro
Brunella
B
Sanguinetti
Maurizio
M
Trapè
Giulio
G
Equitani
Francesco
F
Carotenuto
Mario
M
Leone
Giuseppe
G
D000293:Adolescent; D000328:Adult; D000368:Aged; D002177:Candidiasis / Q000175:diagnosis* / Q000188:drug therapy / Q000209:etiology; D002648:Child; D002908:Chronic Disease; D005260:Female; D019337:Hematologic Neoplasms / Q000150:complications / Q000382:microbiology* / Q000473:pathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D009894:Opportunistic Infections / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome