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Pulmonary fungal infections after bone marrow transplantation
B T Allan1, D Patton, N K Ramsey
1Department of Diagnostic Radiology, University of Minnesota Medical School, Minneapolis.
Abstract:
Of 319 pediatric patients treated with bone marrow transplantation (BMT) during a 10-year period, 27 developed pulmonary fungal infections (PFI). Only 2 patients (7%) survived. Twenty-three patients (85%) had been treated with systemic antifungal therapy immediately before or at the time of diagnosis. Nineteen patients (70%) were neutropenic, and 4 of the 8 patients who were not neutropenic were being treated with systemic steroids for graft vs. host disease (GVHD). Seven patients (26%) died within 7 days of diagnosis. The diagnosis was made ante-mortem in 9 patients (33%). Radiographic abnormalities were variable. At the onset of chest X-ray (CXR) change, the pulmonary infiltrates were unilateral in 14 patients (52%) and, at diagnosis, bilateral in 18 (66%). At diagnosis the infiltrates were interstitial in 3 patients (11%), alveolar in 20 (74%) and mixed in 4 (15%). Six patients (22%) developed cavitary lesions. The infecting agents were Aspergillus in 21 patients (78%), Candida in 7 (26%), Mucormycosis in 3 (11%), and Fusarium in 1 (4%). Five patients (19%) had mixed fungal infections and 7 (26%) had concurrent cytomegalovirus (CMV) pulmonary infections. Although the radiographic changes are often nonspecific in PFI, alveolar or nodular infiltrates in neutropenic patients or in those being treated for GVHD should strongly suggest a fungal etiology.
Insights
Pulmonary fungal infections (PFI) are devastating in pediatric bone marrow transplant (BMT) patients, with a survival rate of only 7%. Early recognition of nonspecific radiographic findings is crucial for timely diagnosis and treatment of PFI post-BMT.
Area of Science:
- Pediatric Hematology-Oncology
- Infectious Diseases
- Pulmonology
Background:
- Bone marrow transplantation (BMT) is a life-saving procedure for pediatric patients with various hematologic and oncologic conditions.
- Pulmonary fungal infections (PFI) are a serious complication following BMT, associated with high morbidity and mortality.
- Identifying risk factors and characteristic clinical and radiographic features of PFI is essential for prompt diagnosis and management.
Purpose of the Study:
- To investigate the incidence, clinical characteristics, diagnostic challenges, and outcomes of pulmonary fungal infections in pediatric patients undergoing BMT.
- To identify specific radiographic patterns and patient factors associated with PFI in this vulnerable population.
- To evaluate the effectiveness of current diagnostic and therapeutic strategies for PFI.
Main Methods:
- Retrospective analysis of 319 pediatric patients who underwent BMT over a 10-year period.
- Detailed review of medical records, including patient demographics, BMT details, clinical presentation, diagnostic workup (radiography, microbiology), treatment, and outcomes.
- Correlation of radiographic findings (chest X-ray, infiltrates, lesions) with patient status (neutropenia, graft-versus-host disease treatment) and identified fungal pathogens.
Main Results:
- Twenty-seven (8.5%) of 319 pediatric BMT patients developed PFI, with a dismal survival rate of 7% (2/27).
- Most patients with PFI were neutropenic (70%) or receiving systemic steroids for graft-versus-host disease (GVHD) (11% of non-neutropenic patients).
- Common pathogens included Aspergillus (78%), Candida (26%), and Mucormycosis (11%). Radiographic findings were variable, with alveolar infiltrates being most common (74%) at diagnosis. Concurrent cytomegalovirus (CMV) infections were noted in 26%.
Conclusions:
- Pulmonary fungal infections pose a significant threat to pediatric BMT recipients, characterized by extremely low survival rates.
- Alveolar or nodular infiltrates on chest imaging in neutropenic patients or those on steroids for GVHD should raise strong suspicion for PFI.
- Improved diagnostic strategies and earlier initiation of appropriate antifungal therapy are critical to improve outcomes for PFI in pediatric BMT survivors.