Adjuvant Corticosteroid Therapy for Chronic Disseminated Candidiasis in Patients with Acute Leukemia

Abstract 4723

Chronic disseminated candidiasis (CDC) is typically observed during neutrophil recovery in patients with acute leukemia and requires protracted antifungal therapy. Our objective was to document the efficacy and tolerance of corticosteroid therapy (CST) in patients with symptomatic CDC, including those who experienced fever and abdominal pain despite ongoing antifungal therapy. We performed a study involving 6 adult patients who experienced ongoing symptomatic CDC despite receipt of appropriate antifungal therapy for whom adjuvant oral CST therapy was initiated. All cases of CDC were proven or probable, as determined on the basis of the European Organization for Research and Treatment of Cancer-Mycosis Study Group definition criteria, and occurred in patients with leukemia.The common manifestations in these six patients were persistent fever, splenohepatomegalia and percussion pain in hepatic region. Meanwhile, 2 of them were accompanied with appearance of painful and diffuse cataneous nodules, expectoration and dyspnoea. The abnormal laboratory test observed of them was increase of alkaline phosphatase. Computed tomography scan showed multiple hypodense lesions in the liver and spleen in all the five patients; one of them showed multiple nodular patchy shadows in bone. Nuclear magnetic resonance imaging showed multiple abnormal signal in liver, spleen and kidneys in one of the patients. Three patients had positive blood candida tropicalis cultures. liver biopsy in one patient was negative for fungal. Two patients received Fluconazole therapy empirically, but it was replaced by Itraconazole later in one because of unresponsiveness to the drug. Three patients received Itraconazole therapy and in one received voriconazole therapy empirically. CDC-attributable clinical symptoms resolved with CST, which was started an average of 31 day since antifungal therapy was initiated. Fever and abdominal pain disappeared a median of 5–6 days, and serum fibrinogen and C-reactive protein levels returned to normal values within 14–30 days. Hepatosplenic microabscesses decreased or disappeared within a mean period of 45 days (range, 27–167 days). All the six patients received further chemotherapy smoothly after the treatment antifungal therapy combined with CST,No relapses of CDC were observed during a median duration of follow-up of 3.2 years (range, 2.6–3.8 years).CONCLUSION: In adults who experience persistently symptomatic CDC despite ongoing receipt of antifungal therapy, CST involving a prednisone equivalent at a dosage of > or =0.25 mg/kg per day for at least 3 weeks is associated with a prompt resolution of symptoms and of inflammatory response. These findings support the pathophysiological hypothesis that CDC belongs to the spectrum of fungus-related immune reconstitution inflammatory syndrome.