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Application of a standardized screening protocol for diagnosis of invasive mold infections in children with
Shannon M Cohn1,2, Hanumantha R Pokala3, Jane D Siegel4
1University of Texas Southwestern Medical Center, Dallas, TX, USA. shannonmitch@gmail.com.
Purpose:
This study describes a standardized screening protocol for diagnosis of invasive mold infections in pediatric oncology patients with neutropenia and prolonged or recurrent fever.
Methods:
A retrospective chart review was performed of children receiving intensive chemotherapy for hematologic malignancies who developed invasive mold infections from 2004 to 2011. Characteristics and outcomes were compared before and after implementation of the screening protocol in November 2006. The screen includes direct nasal endoscopy performed at the bedside by an otorhinolaryngologist, noncontrast computed tomography (CT) of the chest, and abdominal ultrasound in patients with neutropenia and prolonged or recurrent fever.
Results:
Fifty patients had proven, probable, or possible invasive mold infections. Before routine use of direct nasal endoscopy, invasive nasosinal disease was detected in 5 of 19 patients (26 %) and all had a compatible clinical presentation. Thirteen of 31 patients (42 %) in the post-screen group had nasosinal disease, and fever was the only sign for 8 patients (62 %). Twenty-four patients with nasosinal disease had a sinus CT, and radiologic findings of bony erosion or peri-sinus invasion were never detected. Eight of 19 patients in the pre-screen group died from mold infection (42.1 %) versus 4 of 31 (12.9 %) in the post-screen group (p = 0.04).
Conclusions:
A screening protocol including direct nasal endoscopy, noncontrast chest CT, and abdominal ultrasound was effective in detecting invasive mold infections in at-risk patients. Nasosinal involvement often occurs before specific symptoms develop, and sinus CTs are insensitive and nonspecific. Bedside nasal endoscopy precludes radiation exposure associated with sinus CT and was associated with decrease in mold-related mortality, likely due to earlier diagnosis and initiation of appropriate antifungal therapy.
Insights
A new screening protocol effectively detects invasive mold infections in pediatric oncology patients. This method, including nasal endoscopy and imaging, reduced mortality by enabling earlier diagnosis and treatment.
Area of Science:
- Pediatric Oncology
- Infectious Diseases
- Medical Diagnostics
Background:
- Invasive mold infections pose a significant threat to pediatric oncology patients with neutropenia.
- Early and accurate diagnosis is crucial for effective treatment and improved outcomes.
Purpose of the Study:
- To describe and evaluate a standardized screening protocol for diagnosing invasive mold infections in pediatric oncology patients experiencing neutropenia with prolonged or recurrent fever.
- To assess the impact of the protocol on the detection of nasosinus disease and patient mortality.
Main Methods:
- A retrospective chart review compared outcomes before and after implementing a screening protocol in November 2006.
- The protocol involved direct nasal endoscopy, noncontrast chest CT, and abdominal ultrasound for at-risk patients.
Main Results:
- The screening protocol identified invasive mold infections, including nasosinus disease, more effectively in the post-implementation group (42% vs. 26%).
- Nasosinus disease was often detected with fever as the sole symptom, and sinus CT scans showed limited diagnostic value.
- Mortality from mold infections decreased significantly in the post-protocol group (12.9% vs. 42.1%, p=0.04).
Conclusions:
- The standardized screening protocol, incorporating nasal endoscopy and imaging, is effective for early detection of invasive mold infections in immunocompromised children.
- Bedside nasal endoscopy offers advantages over sinus CT, including avoiding radiation exposure and enabling earlier diagnosis.
- The protocol likely contributed to reduced mold-related mortality through timely diagnosis and antifungal therapy initiation.
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