Elsevier

Leukemia Research

Volume 29, Issue 5, May 2005, Pages 493-501
Leukemia Research

Chronic disseminated candidiasis in patients with acute leukemia: emphasis on diagnostic definition and treatment

https://doi.org/10.1016/j.leukres.2004.10.003Get rights and content

Abstract

Background:

Chronic disseminated candidiasis (CDC) is a form of invasive fungal infection that occurs most commonly in patients with acute leukemia treated with chemotherapy. Recent studies have provided evidence for diagnostic alternatives to invasive procedures and more therapeutic options for the management of this complication. In order to put diagnostic criteria and methodological approach to the disease into the perspective of developing strategies for therapy, all relevant studies published in the English literature over the last 30 years were examined.

Materials and methods:

The English-language articles located through MEDLINE (1966 to present) and from selected bibliographies.

Results:

There is increased recognition of CDC as complication of treatment with chemotherapy in patients with acute leukemia. Liver biopsy may not always be revealing or feasible to perform in some patients. Among the imaging modalities, magnetic resonance imaging has obtained preeminence as a non-invasive tool for the diagnosis of hepatosplenic fungal infections. Administration of amphotericin B (Amp B) in relatively large cumulative doses is needed to ensure appropriate control of the infection and prevention of future relapse. Patients intolerant of, or refractory to conventional Amp B have been successfully salvaged using fluconazole or lipid formulations of Amp B. A constellation of clinical, laboratory and radiologic parameters should be used to determine response and efficacy of therapy. There is sufficient evidence to support the safety and feasibility of continuing chemotherapy for acute leukemia in conjunction with antifungal treatment in patients diagnosed with CDC.

Conclusion:

The development of CDC in patients with acute leukemia does not preclude further chemotherapy or constitute contraindication for bone marrow transplantation. Knowledge of the course and pattern of evolution of the disease and adopting aggressive therapeutic approach will likely reduce the morbidity and mortality from this complication.

Section snippets

Incidence and risk factors

Controlled or multi-institutional studies that evaluate the incidence and prevalence of CDC are presently unavailable. The reported frequency of CDC ranges between 3 and 29% depending on the diagnostic criteria used by different investigators. For example, Grois et al. demonstrated the presence of sonographic evidence of CDC in 16 (29%) of the 55 patients with acute leukemia who were screened for this complication regardless of their presentation [9]. Histopathologic proof of the infection,

Presentation and diagnosis

Approximately 85% of the patients with CDC and underlying acute leukemia are in remission at the time of diagnosis [11]. The most common manifestation of CDC is persistent fever not responsive to conventional antibiotics. There may be more than one spike of fever per day associated with chills and rigors with temperature exceeding 40 °C in some patients [1], [2], [3], [11], [26], [28]. Right upper quadrant or abdominal pain is the second most common finding following fever reported by most

Treatment

Because most of the patients are in remission at the time of diagnosis of CDC, the usual dilemma is whether to delay further treatment, i.e., consolidation or maintenance, or to hold further chemotherapy until the infection is completely eradicated. This is an extremely important issue since several months of antifungal treatment may be required to efficiently control this type of invasive candidiasis [11], [43], [44]. The duration of therapy of CDC in relation to the administration of

Conclusion

Infection is the most common complication and likely the most common cause of death in patients with hematologic malignancies. The improvement in supportive care and antibiotic therapy have caused substantial reduction in the morbidity and mortality of these infectious complications. On the other hand, the introduction of more aggressive chemotherapeutic regimens and BMT have resulted in the appearance or the increase in incidence of certain infections with unknown natural history. Among these

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