Reactions 1415 - 18 Aug 2012

SDexamethasone/pegaspargase/vincristine

Disseminated cryptococcosis in a child?: casereport

A 9-year-old boy with acute lymphoblastic leukaemia(ALL) developed life-threatening disseminatedcryptococcosis after receiving dexamethasone, vincristineand pegaspargase.

The boy, who was diagnosed with pre-B cell ALL,completed induction chemotherapy consisting of 4 weeksof oral dexamethasone daily, IV vincristine weekly and asingle dose of IM pegaspargase [doses not stated]. Onday 30 of induction, he presented at an emergencydepartment (ED) with a fever. Tests showed an absoluteneutrophil count of 3900/µL and an absolute lymphocytecount of 4814/µL.

The boy received ceftriaxone, and was discharged. Hereturned to the ED less than 24 hours later, however, withpersistent fever, headache and respiratory distress. Chestx-ray showed bibasilar airspace opacities. He receivedceftazidime, azithromycin and oseltamivir, and wasadmitted for pneumonia. His respiratory status worsenedover the next 24 hours, and he was transferred to apaediatric ICU for septic shock and respiratory failure. Hewas intubated, and received vasoactive agents. Bloodcultures identified yeast, and he started receiving empiricmicafungin and fluconazole. Chest CT showed bilateralground-glass opacities and lymphadenopathy, while asepsis evaluation revealed cryptococcal antigen in his CSF.Blood cultures from his initial presentation grewCryptococcus neoformans, and his serum cryptococcalantigen was positive. He then started receiving liposomalamphotericin B and flucytosine. His condition continued toworsen, requiring increased haemodynamic andventilatory support. Flucytosine was switched to IVfluconazole, and amphotericin B was increased. His bloodcultures were negative after 5 days of antifungal therapy;however, he remained intubated for over 2 weeks. ACD4 lymphocyte count, taken after 10 days of illness, wasconsistent with moderate immunosuppression.Approximately 3 weeks after his initial fever, he hadstabilised, with no further manifestations of cryptococcalinfection. He restarted chemotherapy with methotrexateand mercaptopurine, with 3 weeks of "maintenance-like",followed by standard consolidation with mercaptopurine,methotrexate and a single dose of IV vincristine 2 mg/m2.He remained on oral fluconazole until 6 months aftercompletion of chemotherapy. At last follow-up, heremained free of fungal disease, without neurologicaldeficits.

Author comment: "Despite the fact that patients withleukemia are immunosuppressed from both their underlyingdisease and treatment regimen, cryptococcal infectionremains an unusual complication."Heath JL, et al. Successful treatment of disseminated cryptococcal infection in apediatric acute lymphoblastic leukemia patient during induction. Journal ofPediatric Hematology/Oncology 34: e161-3, No. 4, May 2012 - USA 803075474

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Reactions 18 Aug 2012 No. 14150114-9954/10/1415-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved