An 8-year-old male student, resident in Santiago, with a history of acute myeloid leukemia (AML) M4, who underwent a transplant of hematopoietic precursors (HSCT) one year before and after admission.
The patient developed a relapse of her leukemia and received a chemotherapy cycle in preparation for a new HSCT.
Eight days later, the patient was hospitalized for an episode of febrile neutropenia, so vancomycin, ceftazidime and amikacin were started.
The patient complained of pain in the right nostril and upper nasal fossa. Four days after admission, she complained of mild erosion of the right nostril with signs of recent bleeding and a lower nasal septum.
The latter was removed and sent to bacterial culture and isolation.
Under the crust, there was a lesion of the septal leaflet more adhered and septal defect, whose surface was removed without bleeding.
He was sent to calcofluor staining, which showed septate hyphae. Voriconazole 9 mg/kg/dose twice daily was started.
Computed tomography (CT) of the paranasal cavities showed pansinusal inflammatory changes without extrasinusal extension.
Early nasal endoscopic surgery was performed, consisting of a right sphenoidotomy with resection of necrotic nasal septum and left septal cartilage.
Samples of the superior turbinate and right sphenoid, nasal septum mucosa and left septal cartilage were sent for biopsy.
The first two were also sent to calcofluor staining and were negative for bacterial culture.
Samples were placed in Sabouraud dextrose agar at room temperature and at 35 °C.
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The surgical sample of nasal septum and septal cartilage showed at 48 h development of 4-6 mm colonies, cottony, yellowish appearance of dust, holstein, and white or greyish color.
The right sphenoid sample was negative.
Microscopy revealed dematiaceous hyphae with light brown conidiophores, septate, solitary and geniculate, and zygous sprouting in the apical region.
These were brown, cylindrical junctions, with thick pigmented walls, with three hyptes and four cells, with dark brown atricides.
Based on macroscopy and microscopy, the agent was identified as Curvularia spicifera.
For gender confirmation, a universal polymerase chain reaction (PCR) was performed and subsequent sequencing of the ITS1, ITS4 and 5.6S rRNA gene segments to the developed colonies, identifying them.
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Biopsy of the mucosa of the nasal septum and left septal cartilage showed extensive areas of destruction, necrosis, ulceration and hemorrhage associated with the presence of abundant philosophic elements histo and angioinvasive.
Mycotic elements corresponded to tabicline hyaline filamentos with some balloon dilations and growth varying from 45° to 90°, with hyalohifomicete characters.
The sample of the osteochondroma-mucosal wall of comet and right sphenoid showed only signs of chronic active nonspecific inflammation.
In order to study the antifungal susceptibility, colonies obtained on Sabouraud agar were sealed in water agar to increase the production of infected agar.
Microdilution was performed according to CLSI, document M38-A2, and was sensitive to the three antifungals studied, with MIC to amphotericin B of 1 μg/ml, posaconazole 0.25 μg/ml and voriconazole 0.25 μg/ml.
After the etiological identification, the antifungal scheme was adjusted associating liposomal amphotericin 5 mg/kg/day and a new surgical procedure was performed two days later with negative calcifying and nasal culture without necrosis.
Signaling melanoma remained negative in blood.
He received voriconazole for 40 days, with variable plasma concentrations between 0.2-1.6 mg/L (therapeutic range 1-5 mg/L) and liposomal amphotericin for 25 days (cumulative dose 125 mg/kg).
It was established in a satisfactory way from the otorhinological point of view.
She received a second HSCT, with no skin lesions or nasal symptoms in the following months.
However, infectious reconstitution was not achieved and the patient died due to other complications.
