Invasive mold infections of the central nervous system in patients with hematologic cancer or stem cell transplantation (2000–2016): Uncommon, with improved survival but still deadly often. Issue 6 (December 2017)

• Record Type: Journal Article
• Authors: Economides, Minas P.; Ballester, Leomar Y.; Kumar, Vinodh A.; Jiang, Ying; Tarrand, Jeffrey; Prieto, Victor; Torres, Harrys A.; Kontoyiannis, Dimitrios P.
• Is Part Of: Journal of infection. Volume 75:Issue 6(2017)
• Page Start: 572
• Page End: 580
• Publication Date: 2017-12
• Subjects: Molds -- CNS -- Cancer -- Leukemia -- Stem cell transplantation -- Aspergillus -- Mucorales -- Surgery; Infection -- Periodicals; Bacterial Infections -- Periodicals; Communicable Diseases -- Periodicals; Electronic journals; 616.905
• DOI: 10.1016/j.jinf.2017.09.011
• Languages: English
• ISSNs: 0163-4453

Abstract

Highlights: Incidence and mortality of CNS mold infections has not decreased in the last 16 years. Most patients had CNS infection through hematogenous spread from fungal pneumonia. Aspergillus and Mucorales accounted for 85% of microbiologically-documented cases. Active hematologic cancer, neutropenia and corticosteroids were common (95%, 53%, 78% respectively). Most patients received combination therapy (83%) but 42 day mortality was 48%. Summary: Background: Historically considered to have very poor outcome, there is paucity of recent data regarding invasive mold infections (IMIs) of the central nervous system (CNS) in patients with hematologic cancer (HC) or stem cell transplantation (SCT). Methods: We reviewed the records of HC patients and/or SCT recipients who were diagnosed with CNS IMIs (EORTC/MSG criteria) at MD Anderson Cancer Center (1/1/2000-6/31/2016). Risk factors for survival at day (d) 42 post diagnosis were assessed. Results: We identified 40 such patients (16 with proven infection). The incidence density was 3.8 cases/100000 patient days and mortality remained stable throughout the study period. Most patients had active HC and neutropenia at diagnosis (95% and 53% respectively). Of the 25 patients with a microbiological diagnosis, Aspergillus spp and Mucorales accounted for 85% of cases. CNS IMIs were deemed to be secondary to hematogenous spread in 31 (77%), mostly (90%) fungal pneumonia. CNS lesions typically presented as solitary ring-enhancing abscesses in MRI (26; 65%). Most patients (34; 85%) received lipid AMB and were treated with combination therapy (33; 83%); Mortality 42d was 48%. In univariate analysis, lack of surgical drainage ( p = 0.01), absence of giant cells ( p = 0.01) and granulomas ( p = 0.03) were associated with increased 42d mortality. In multivariate analysis, co-infection was associated with increased ( p = 0.005), while steroid tapering was associated with decreased mortality ( p = 0.01). Conclusions: Although less lethal, improved outcome in these uncommon infections was related only to immune response in histopathology, steroid tapering and possibly surgical drainage. In a contemporary 16-year cohort of 40 patients with hematologic cancer and mold infections of Central Nervous System, 42-day mortality was 48%. Improved survival was related to immune response in histopathology, absence of co-infections, corticosteroid tapering and possibly surgical drainage.