Diagnosis at first sight
Unusual finding in Gram staining of blood cultures in a patient with prolonged febrile neutropenia and acute myeloid leukaemia
Hallazgo inusual en la tinción Gram de hemocultivos en una paciente con neutropenia febril prolongada y leucemia mieloide aguda
Julián Andrés Hoyos-Pulgarína,b, Deving Arias-Ramosb,c,
, Jaime Alberto Gonzalez-Diazd, Natalia Maria Ramireze
Corresponding author
a Medicina Interna y Enfermedades Infecciosas, Oncólogos de Occidente, Pereira, Colombia
b Grupo de Investigación en Medicina Interna, Universidad Tecnológica de Pereira, Pereira, Colombia
c Medicina Interna, Universidad Tecnológica de Pereira, Pereira, Colombia
d Medicina Interna, Hematología y Oncología, Oncólogos del Occidente, Armenia, Colombia
e Medicina general, Oncólogos del Occidente, Armenia, Colombia
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A. Skin lesions in the form of round violaceous macules on the lower limbs. B. Computed tomography of the chest: consolidation in the left upper lobe with no halo sign and no cavitation. C. Gram stain of blood cultures: round and oval structures consistent with macroconidia.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 32-year-old Colombian woman was hospitalised with a diagnosis of acute myeloid leukaemia for administration of induction chemotherapy with idarubicin and cytarabine. After finishing the first cycle of chemotherapy, she presented febrile neutropenia and grade <span class="elsevierStyleSmallCaps">1</span> mucositis. Blood cultures were negative. She received piperacillin/tazobactam and improved. Seven days later, she once again presented with febrile neutropenia, cough, nasal secretion, pain in the paranasal sinuses, generalised myalgia and exanthema in the form of round violaceous macules on the lower limbs and trunk (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Blood cultures were taken again and treatment was started with meropenem and vancomycin, with no improvement. The patient underwent a chest X-ray and then a computed tomography scan of the chest which showed a consolidation in the left upper lobe with no halo sign or cavitation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). A computed tomography scan of the paranasal sinuses showed bilateral ethmoid maxillary sinusitis with perforation of the septum. The patient was not receiving antifungal prophylaxis. Due to these findings, an invasive fungal infection was suspected and treatment was started with voriconazole 6 mg/kg every 12 h for the first 24 h and then 4 mg/kg every 12 h, and liposomal amphotericin B at 3 mg/kg/day. The laboratory reported growth in blood cultures and the Gram stain showed the structures presented in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Clinical course</span><p id="par0010" class="elsevierStylePara elsevierViewall">Our centre lacks techniques for galactomannan and 1,3-®<span class="elsevierStyleSmallCaps">d</span>-glucan detection; therefore, they were not used. Skin biopsies were not taken either. Round, white, flat and hairy colonies grew in a blood agar medium (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A), and a stain with KOH showed hyaline septate hyphae with branching at an acute angle (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). A differential diagnosis was established between <span class="elsevierStyleItalic">Aspergillus</span> spp., <span class="elsevierStyleItalic">Fusarium</span> spp. and <span class="elsevierStyleItalic">Scedosporium</span> spp., since wide hyaline hyphae with 90° branching are typically seen in mucormycosis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The isolate was sent to a reference laboratory (Corporación para Investigaciones Biológicas [Corporation for Biological Research], in Medellín, Colombia), where it was confirmed to correspond to <span class="elsevierStyleItalic">Fusarium</span> spp. (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C). The patient showed recovery from neutropenia, and her fever and skin lesions disappeared. A decision was made to complete 6 weeks of antifungal treatment and then continue with voriconazole for a year.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Final remarks</span><p id="par0015" class="elsevierStylePara elsevierViewall">This case presented the typical clinical signs of an invasive fungal infection caused by <span class="elsevierStyleItalic">Fusarium</span> spp.; the finding of macroconidia on the Gram stain of the blood cultures supported this diagnosis. <span class="elsevierStyleItalic">Fusarium</span> spp. and <span class="elsevierStyleItalic">Scedosporium</span> spp. cause intravascular sporulation and skin lesions, and blood cultures are usually positive in both cases but more commonly in infections due to <span class="elsevierStyleItalic">Fusarium</span> spp. Infection with <span class="elsevierStyleItalic">Fusarium</span> spp. presents with myalgia in up to 15% of cases and examination under a microscope reveals macroconidia in the shape of a banana,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> typical findings in our case. Although invasive sinusitis occurs in infections due to <span class="elsevierStyleItalic">Aspergillus</span> spp. and zygomycetes, their clinical behavior is more serious and rapidly progressive; furthermore, <span class="elsevierStyleItalic">Aspergillus</span> spp. rarely presents with positive blood cultures.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Patients with haematological malignancies are at higher risk of invasive fungal infection due to filamentous fungi and the incidence is highest in patients with acute myeloid leukaemia. In these cases, soft tissue involvement may be a sign of infection with <span class="elsevierStyleItalic">Pseudomonas aeruginosa (ecthyma gangrenosum)</span>, <span class="elsevierStyleItalic">Staphylococcus aureus</span> or filamentous fungi such as <span class="elsevierStyleItalic">Aspergillus</span> spp., zygomycetes and <span class="elsevierStyleItalic">Fusarium</span> spp.,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> or due to a non-infectious aetiology such as drug reactions, Sweet's syndrome, erythema multiforme or leukaemia cutis. The presence of skin lesions in a "bull's-eye" pattern may lead to consideration of a diagnosis of disseminated fusariosis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Invasive scedosporiosis is also accompanied by non-pruriginous, erythematous and nodular skin lesions, with a necrotic centre.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Invasive fusariosis is a rare disease, with an incidence of 0.1%, but a high mortality rate, up to 53%.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Fungaemia is a distinctive characteristic of invasive fusariosis compared to other opportunistic infections caused by fungi. Prompt identification is required to quickly start treatment with effective antifungal agents (voriconazole, amphotericin B or posaconazole), although rates of clinical response are modest.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> We wish to stress the importance of collaboration with the microbiology laboratory and morphological analysis of fungi, which are necessary for differential diagnosis and appropriate treatment in patients with prolonged febrile neutropenia.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical course" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Final remarks" ] 3 => array:2 [ "identificador" => "xack475540" "titulo" => "Acknowledgments" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Hoyos-Pulgarín JA, Arias-Ramos D, Gonzalez-Diaz JA, Ramirez NM. Hallazgo inusual en la tinción Gram de hemocultivos en una paciente con neutropenia febril prolongada y leucemia mieloide aguda. Enferm Infecc Microbiol Clin. 2020;38:338–340.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1031 "Ancho" => 1500 "Tamanyo" => 212891 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical, radiological and microbiological findings. A. Skin lesions in the form of round violaceous macules on the lower limbs. B. Computed tomography of the chest: consolidation in the left upper lobe with no halo sign and no cavitation. C. Gram stain of blood cultures: round and oval structures consistent with macroconidia.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1270 "Ancho" => 1750 "Tamanyo" => 191018 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Macroscopic and microscopic findings. A. Blood agar: hairy, flat, white and round colonies. B. Preparation with KOH of the blood agar plate: hyaline septate hyphae with branching at an acute angle and macroconidia are observed. C. Oatmeal agar: greyish-white colonies with a smooth and cottony appearance.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Candida</span> and invasive mould diseases in non-neutropenic critically ill patients and patients with haematological cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.L. Colombo" 1 => "J.N. de Almeida Júnior" 2 => "M.A. Slavin" 3 => "S.C.A. Chen" 4 => "T.C. Sorrell" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s1473-3099(17)30304-3" "Revista" => array:6 [ "tituloSerie" => "Lancet Infect Dis." 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"fecha" => "2016" "volumen" => "71" "numero" => "suppl 2" "paginaInicial" => "ii31" "paginaFinal" => "ii36" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27880667" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack475540" "titulo" => "Acknowledgments" "texto" => "<p id="par0030" class="elsevierStylePara elsevierViewall">We would like to thank the Oncólogos de Occidente [Western Oncologists] health institution.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/2529993X/0000003800000007/v1_202008020607/S2529993X20301313/v1_202008020607/en/main.assets" "Apartado" => array:4 [ "identificador" => "63560" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Diagnosis at first sight" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/2529993X/0000003800000007/v1_202008020607/S2529993X20301313/v1_202008020607/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X20301313?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 1 | 3 |
| 2024 October | 24 | 7 | 31 |
| 2024 September | 21 | 11 | 32 |
| 2024 August | 26 | 10 | 36 |
| 2024 July | 23 | 6 | 29 |
| 2024 June | 26 | 2 | 28 |
| 2024 May | 13 | 4 | 17 |
| 2024 April | 46 | 5 | 51 |
| 2024 March | 32 | 4 | 36 |
| 2024 February | 36 | 4 | 40 |
| 2024 January | 50 | 5 | 55 |
| 2023 December | 51 | 5 | 56 |
| 2023 November | 36 | 7 | 43 |
| 2023 October | 43 | 3 | 46 |
| 2023 September | 27 | 2 | 29 |
| 2023 August | 36 | 3 | 39 |
| 2023 July | 50 | 2 | 52 |
| 2023 June | 37 | 2 | 39 |
| 2023 May | 54 | 2 | 56 |
| 2023 April | 67 | 2 | 69 |
| 2023 March | 79 | 3 | 82 |
| 2023 February | 53 | 4 | 57 |
| 2023 January | 58 | 7 | 65 |
| 2022 December | 40 | 4 | 44 |
| 2022 November | 41 | 11 | 52 |
| 2022 October | 43 | 7 | 50 |
| 2022 September | 42 | 13 | 55 |
| 2022 August | 35 | 12 | 47 |
| 2022 July | 16 | 9 | 25 |
| 2022 June | 19 | 6 | 25 |
| 2022 May | 30 | 12 | 42 |
| 2022 April | 39 | 5 | 44 |
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| 2022 February | 38 | 7 | 45 |
| 2022 January | 63 | 7 | 70 |
| 2021 December | 57 | 7 | 64 |
| 2021 November | 33 | 6 | 39 |
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| 2021 September | 14 | 5 | 19 |
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| 2021 June | 12 | 4 | 16 |
| 2021 May | 18 | 6 | 24 |
| 2021 April | 51 | 1 | 52 |
| 2021 March | 27 | 4 | 31 |
| 2021 February | 10 | 5 | 15 |
| 2021 January | 1 | 0 | 1 |
| 2020 August | 12 | 2 | 14 |
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