Akut lenfoblastik lösemili bir olguda gelişen nöroaspergillozun başarılı tedavisi: Cerrahi, sistemik antifungal tedavi ve intrakaviter tedavinin rolleri
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Date
2009-07
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Ankara Mikrobioloji Derneği
Abstract
Serebral aspergilloz nadir bir durum olup konvansiyonel antifungal tedavilere genellikle kötü yanıt vermektedir. Bu raporda, 34 yaşında akut lenfoblastik lösemi tanısı olan bir erkek hastada agresif nörocerrahi, intrakaviter amfoterisin B tedavisi ve vorikonazol kombinasyonu ile başarıyla tedavi olan bir serebral aspergilloz olgusu sunulmuş ve nöroaspergillozun tedavisinde cerrahi tedavi, intrakaviter tedavi ve antifungal tedavinin rolleri tartışılmıştır. Amfoterisin B tedavisi altında dizartri ve sağ hemiparazi gelişen olgumuzda beyin manyetik rezonans görüntülemede sol paryeto-oksipital bölgede 7 cm çapında lezyon saptanmıştır. Tanı amaçlı yapılan cerrahi girişim aşırı kanama nedeniyle başarıyla gerçekleştirilememiştir. Lezyondan alınan aspirat örneğinin kültüründe Aspergillus flavus üremesi saptanmıştır. Tedavi kaspofungin ve vorikonazol kombinasyonu olarak değiştirilmiştir. Tedavi altında enfeksiyonun ilerleme göstermesi üzerine hastaya ikinci cerrahi girişim uygulanmış ve lezyonun boyutunda gerileme tespit edilmiştir. Cerrahi tedaviyi takiben vorikonazol ve kaspofungin kombinasyon tedavisine ek olarak intrakaviter amfoterisin B uygulaması yapılmıştır (0.3 mg/gün 15 gün). Kaspofungin tedavisine 42 gün devam edildikten sonra kesilmiştir. Vorikonazol tedavisine ise 100 gün devam edilmiştir. Bu dönemde beyindeki lezyon tama yakın düzelme göstermiştir. Ancak, hastanın takibi sırasında lösemi relapsı görülmüş ve kemoterapi sırasında aplazik dönemde gelişen nötropenik tiflitis tablosu ile hasta kaybedilmiştir. Serebral aspergillozlu olgularda erken dönemde radikal cerrahi uygulanması sonucunda daha iyi sonuçlar elde edildiği belirtilmektedir. Antifungal tedavide kullanılan ilaçların vorikonazolde olduğu gibi kan-beyin bariyerini geçebilme özelliğine sahip olması gerekmektedir. Tüm lezyonlar düzelinceye ve altta yatan predispozan faktörler geri dönünceye kadar tedaviye devam edilmelidir. Sonuç olarak, serebral aspergillozlu olgularda cerrahi girişim ve vorikonazol tedavisinin güvenilir ve etkin tedavi yaklaşımları olduğu düşünülmüştür.
Cerebral aspergillosis is a rare condition that generally exhibits a poor response to conventional antifungal drugs. We report here a case of cerebral aspergillosis in a 34-years-old man with acute lymphoblastic leukaemia who was successfully treated with a combination of aggressive neurosurgery, intracavitary instillation of amphotericin B and voriconazole. We aimed to emphazise the roles of surgery, intracavitary therapy and antifungal therapy in the management of neuroaspergillosis. Under amphotericin-B therapy, the patient developed dysarthria and paralysis of the right side of his body. Brain magnetic resonance imaging demonstrated a lesion in the left parieto-occipital region, measuring 7 cm in the greatest dimension. Diagnostic surgery was interrupted due to abundant bleeding. The culture of the aspirate from the lesion yielded Aspergillus flavus. The therapy was switched to voriconazole and caspofungin combination. Due to disease progression during combination therapy, the patient had a second surgical resection resulting in a 75% reduction in lesion size. Following surgical intervention, intracavitary instillation of amphotericin B (0.3 mg/day for 15 days) was performed alongside with combination therapy (voriconazole and caspofungin). Caspofungin was stopped after 42 days, whereas the patient was continued on voriconazole for a total of 100 days. At this point, his brain lesion resolved almost completely. However, leukemia relapsed. The patient died during his treatment course because of neutropenic typhilitis occurring in the aplastic phase. It is stated that in patients with neuroaspergillosis radical neurosurgery leads to better outcomes if performed at an earlier stage. Antifungal treatment of cerebral aspergillosis requires that the drug must cross the blood brain barrier. Voriconazole has the ability to cross the blood brain barrier. The therapy should be prolonged beyond the resolution of all lesions and until reversal of the underlying predisposition. We conclude that the use of neurosurgery and voriconazole together appears to be a reliable and effective treatment modality in patients with cerebral aspergillosis.
Cerebral aspergillosis is a rare condition that generally exhibits a poor response to conventional antifungal drugs. We report here a case of cerebral aspergillosis in a 34-years-old man with acute lymphoblastic leukaemia who was successfully treated with a combination of aggressive neurosurgery, intracavitary instillation of amphotericin B and voriconazole. We aimed to emphazise the roles of surgery, intracavitary therapy and antifungal therapy in the management of neuroaspergillosis. Under amphotericin-B therapy, the patient developed dysarthria and paralysis of the right side of his body. Brain magnetic resonance imaging demonstrated a lesion in the left parieto-occipital region, measuring 7 cm in the greatest dimension. Diagnostic surgery was interrupted due to abundant bleeding. The culture of the aspirate from the lesion yielded Aspergillus flavus. The therapy was switched to voriconazole and caspofungin combination. Due to disease progression during combination therapy, the patient had a second surgical resection resulting in a 75% reduction in lesion size. Following surgical intervention, intracavitary instillation of amphotericin B (0.3 mg/day for 15 days) was performed alongside with combination therapy (voriconazole and caspofungin). Caspofungin was stopped after 42 days, whereas the patient was continued on voriconazole for a total of 100 days. At this point, his brain lesion resolved almost completely. However, leukemia relapsed. The patient died during his treatment course because of neutropenic typhilitis occurring in the aplastic phase. It is stated that in patients with neuroaspergillosis radical neurosurgery leads to better outcomes if performed at an earlier stage. Antifungal treatment of cerebral aspergillosis requires that the drug must cross the blood brain barrier. Voriconazole has the ability to cross the blood brain barrier. The therapy should be prolonged beyond the resolution of all lesions and until reversal of the underlying predisposition. We conclude that the use of neurosurgery and voriconazole together appears to be a reliable and effective treatment modality in patients with cerebral aspergillosis.
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Keywords
Antifungal therapy, Cerebral aspergillosis, Intracavitary therapy, Neurosurgery, Cerebral aspergillosis, Voriconazole, Microbiology, Serebral aspergilloz, Nörocerrahi, Antifungal tedavi, İntrakaviter tedavi
Citation
Özçelik, T. vd. (2009). "Akut lenfoblastik lösemili bir olguda gelişen nöroaspergillozun başarılı tedavisi: Cerrahi, sistemik antifungal tedavi ve intrakaviter tedavinin rolleri". Mikrobiyoloji Bülteni, 43(3), 499-506.