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Short Course 05 - Histopathology and Mycology of Fungal Infections
Monday, September 18, 2006 14:00 - 17:30
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Moderators:
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Michel Huerre, Institut Pasteur, Paris, France
Gary W. Procop, The Cleveland Clinic, Cleveland, OH
Mary Klassen-Fischer, Armed Forces Institute of Pathology, Washington, DC
Randall T. Hayden, St. Jude Children's Research Hospital, Memphis, TN
Glenn D. Roberts, Mayo Clinic, Rochester, MN
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Disclosure:
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In accordance with ACCME guidelines regarding disclosure, the USCAP policy requires that faculty members who have a significant financial or other relationship with a commercial company, entity, or service (which will be discussed in this Short Course) must disclose this to attendees. The Academy also requires that speakers disclose any products that are not labeled for the use under discussion. Gary W. Procop indicated is receives royalties from Biotage. Randall T. Hayden indicated he is a consultant for Bio-Rad Laboratories. All other faculty members for this Short Course have indicated they have no disclosures to make.
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Clinical histories are displayed below.
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Submitted by: Michel Huerre, Eric Dannaoui and Michel Develoux
Submitted by: Gary W. Procop
The patient was a 53 year old man with sarcoidosis on mycophenolate, prednisone, plaquenil and had recently received his first dose of remicade for steroid refractory disease. He had chronic erythematous papules without ulceration on the ankles bilaterally and onychomycosis. The papules were biopsied at an outside hospital and read as "deep seated fungal infection, cryptococcus vs. blastomyces, and submitted to the Cleveland Clinic for further evaluation. The culture isolate recovered from the biopsy, and the biopsy materials were reviewed (biopsy presented here). The patient had no systemic symptoms and no evidence of pulmonary disease.
Case 1 - Figure 1
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Case 1 - Figure 2
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The patient was a 63 year old man with chronic lymphocytic leukemia, associated thrombocytopenia, and pneumonia. His past medical history consisted of neutropenic fever five months prior to admission for which he finished a course of augmentin, voriconazole and ciprofloxacin. Due to residual pneumonia, thought possibly to be caused by a fungus based on a previous CT scan, the patient continued voriconazole and levaquin for another 14 days. This seemed to resolve by CT by three months prior to admission, but the Infectious Diseases clinician decided to continue with acyclovir and levaquin prophylaxis. Patient also continued chemotherapy cycles during this time period as tolerated.
Case 2 - Figure 1
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Case 2 - Figure 2
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Submitted by: Mary Klassen-Fischer
The patient was a 61 year old white male from Texas admitted to the hospital from the diabetic clinic with complaints of malaise for one month, anorexia and weight loss of approximately 16 kg (35 pounds) occurring over the past year, but most pronounced over the past 2 months. Three weeks prior to admission, he had a few episodes of nausea and vomiting. Two weeks prior to admission, he developed right pleuritic chest pain, non-productive cough, afternoon fevers to 38.5 ºC (101º F) and chills but no night sweats or hemoptysis.
Case 3 - Figure 1
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Submitted by: Randall T. Hayden
The patient was three-year old male, diagnosed with acute myeloid leukemia, who developed fever and neutropenia after admission for his first course of induction chemotherapy. Blood cultures were negative. One week later, chest radiograph showed a right lower lobe infiltrate accompanied by a right pleural effusion. The radiologist's interpretation was pneumonia vs. atelectasis.. Antifungal therapy was added to the patient's antimicrobial regimen. Two weeks after the patient's initial presentation, he experienced a new febrile episode, (Tmax, 38.6°C). The patient improved clinically on broad-spectrum antibiotic and antifungal therapy, but one week later presented with an evolving eschar with underlying erythema over his left knee. No evidence of joint involvement was seen, and radiographic exams showed no bony involvement. One week later the patient reported bilateral ear pain with exam showing otitis externa and retracted tympanic membranes. Five days later an erythematous lesion was noted on the patient's right thigh and right external ear. An infectious disease consultation was requested. Physical exam was remarkable for a 5x5 cm eschar with underlying erythema over the left knee, a 5mm erythematous lesion over the right ventral thigh and a 7-8 mm scab lesion over the left ventral thigh. The right pinna was also erythematous, without tenderness. Laboratory results were significant for an absolute neutrophil count of 0 and several series of negative blood cultures. Chest, abdominal and pelvic CT scans were significant for cervical, submandibular, and submental lymphadenopathy. Chest radiograph showed mild peri-bronchial thickening, but no focal opacities. Shave biopsies of the patient's cutaneous lesions on the right pinna, right anterior proximal thigh, and left knee were performed. H&E and GMS-stained slides of the right pinna were provided for your examination. Results of fungal culture revealed Fusarium species.
Case 4 - Figure 1
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Case 4 - Figure 2
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