TRICHOSPORON ASAHII DISSEMINATED INFECTION IN A NEUTROPENIC PEDIATRIC PATIENT WITH HIGH-RISK ACUTE LYMPHOBLASTIC LEUKEMIA

Purpose: The purpose of this study is to report a fatal case of infection caused by Trichosporon asahii in a pediatric patient with acute lymphoblastic leukemia (ALL) and to present an update on systemic trichosporonosis in neutropenic patients with special reference to the treatment and diagnosis of Amphotericin B resistant infections. Methods: A 4-year-old girl was admitted to the hospital with recurrent fevers, bone pain, malaise, and pancytopenia. She was diagnosed with B precursor ALL and a history of asthma and prior corticosteroid treatment. She was started on a an ALL treatment protocol (AALL 1131) as high risk due to prior treatment with steroids. At day 15 of her remission induction therapy, her management was complicated by her left arm suddenly becoming painful and edematous, and she spiked a fever (T-max 40.4° C). Blood cultures Trichosporon yeast species and her absolute neutrophil count (ANC) was 0. She was started on amphotericin B and her CVC was removed. The organism was identified as Trichosporon asahii, a fungal species known for multi-drug resistance. She was then started on voriconazole and continued Amphotericin B and Cefepime for fungal and broad-spectrum bacterial coverage. As her infection persisted, T. asahii was repeatedly demonstrated in blood cultures. Results: In the days following, she developed an oxygen requirement, her abdomen became distended and firm, there was a significant decrease in urine output, and a sonogram showed pyelonephritis. Both lower extremities became edematous and scattered red papules developed on her abdomen, chest, face, and back. She was moved to the PICU 17 days from admission. On day 18, she required intubation and pressor support, G-CSF was started, and the first signs of multi-organ failure were evident. On the 23rd day from her admission, life-supporting measures were discontinued at the request of the family and she died at 1:10am. Post-mortem it was determined that the strain of T. asahii grown from her blood cultures was resistant to amphotericin B and micafungin, but sensitive to voriconazole. Conclusions: With greater awareness of etiologic significance of T. asahii and its drug resistance, future cases of trichosporonosis are more likely to be identified early, based on culture sensitivity, and evaluated for innovative antifungal therapy.