Case Presentation: A 52-year-old man with a history of cutaneous T-cell lymphoma stage IVb and T-lineage acute lymphoblastic lymphoma admitted for fever and neutropenia. On previous admission for induction chemotherapy he developed oral mucositis, clostridium difficile colitis treated with oral vancomycin, and a lower extremity deep vein thrombosis treated with enoxaparin. Readmission presentation included fever, cough, and bloody oral secretions. Patient was febrile to 102ºF, normotensive, and mildly tachycardic. On exam, oral mucositis and chronic right upper extremity wound secondary to T-cell lymphoma were present. White blood cell count 100/µL, hemoglobin 7.1 gm/dL, and platelets 36,000/µL. Cefepime was initiated and he was continued on immunosuppressive prophylactic antimicrobials. He became hypotensive and vancomycin and acyclovir were added. Initial blood and urine cultures were negative. Chest computed tomography revealed bilateral pulmonary emboli. Blood cultures grew yeast and anidulafungin was added. He was intubated for increased oxygen requirement and worsened mentation. He developed renal failure secondary to septic shock despite antibiotic coverage and pressor support. Care was withdrawn. Final blood cultures resulting just after death grew Lomentospora prolificans.
Discussion: Lomentospora prolificans is an emerging fungal infection with mortality rates around 90%. Found at higher concentrations in agricultural soil and polluted water, it has been reported in Australia, Spain, and southern United States. Multidrug resistance is reported against echinocandins, pyrimidines, allylamines, polyenes and to some degree azoles. It can be colonized, localized or cause disseminated infection. Neutropenia, transplant, hematological malignancies, and autoimmune immunodeficiency syndrome (AIDS) are risk factors for disseminated presentation.
Limited treatment information exists. Studies show a combination approach as more successful. A synergistic interaction is seen between voriconazole and amphotericin B or echinocandins as well as in the combination of terbinafine, itraconazole and miconazole. Immunocompromised hosts need immune assistance to fight infection. Trials show granulocyte macrophage-colony stimulating factor in combination with interferon gamma increase polymorphonuclear neutrophils ability to damage hyphae. A novel class of antifungal, E 1210 shows minimum inhibitory concentrations in vitro ten times lower than current treatment with voriconazole.
Conclusions: Lomentaspora prolificans in immunocompromised hosts results in disseminated infection with high mortality. An internist should consider Lomentospora in an immunocompromised patient with clinical deterioration, especially in the southern United States. Terbinafine in combination with an azole is a reasonable initial empiric treatment option.