Breakthrough Invasive Fungal Infections in Allogeneic Hematopoietic Stem Cell Transplantation

Area of Science:

• Hematology
• Infectious Diseases
• Mycology

Background:

• Breakthrough invasive fungal infections (b-IFI) are a significant concern in hematological patients and allogeneic hematopoietic stem-cell transplantation (HSCT) recipients.
• Despite mold-active antifungal prophylaxis (MAP), b-IFI can lead to morbidity and mortality.
• Limited data exist on the incidence and types of b-IFI, which are often caused by non-Aspergillus molds.

Observation:

• This report details two rare cases of b-IFI in HSCT patients receiving MAP.
• These cases highlight the challenges in managing b-IFI due to limited prospective trial data and high mortality rates.

Findings:

• b-IFI in this context are frequently caused by non-fumigatus Aspergillus and non-Aspergillus molds.
• Patient characteristics and specific antifungal prophylaxis influence b-IFI occurrence.
• Effective management requires careful consideration of risk factors, prophylaxis, patient conditions, and local epidemiology.

Implications:

• Early broad-spectrum preemptive therapy, including lipid amphotericin-B and a mold-active azole (with or without terbinafine), is recommended.
• This approach aims to cover azole-susceptible/resistant strains and atypical infections.
• Aggressive diagnostic work-up for species identification is essential for guiding targeted therapy and improving outcomes in HSCT patients.