Primary cutaneous invasive Aspergillus infection at a Hickman catheter site l to chest wall involvement and central venous suppurative thrombophlebitis in a patient with relapsed acute myelogenous leukemia.
Primary cutaneous invasive Aspergillus infection at a Hickman catheter site l to chest wall involvement and central venous suppurative thrombophlebitis in a patient with relapsed acute myelogenous leukemia. Therapy included high-dose amphotericin B serial grief debridements pending bone marrow regaining and definitive resection of the infected chest wall and thrombos internal jugular, subclavian, and innominate veins. To our knowledge, this management for control of invasive fungal infection has not been reported previously.
Fungal infections often occur in immunocompromised patients. Treatment includes intravenous antifungal agents and removal of foci of infection if possible. This report describes a patient with progressive Aspergillus invasion of the chest wall and central veins in whom antidote required resection of a major section of the anterior chest wall as well as central veins to include the internal jugular, subclavian, and innominate veins, a action not previously described for fungal infection.
CASE REPORT
A 28-year-old male patient was initially treated for acute myelogenous leukemia in April 1990 and remission was achieved. A routine follow-up descendants smear in February 1992, however, showed blast small cavitys The WBC count as 1900/[mmsup3] with no neutrophils seen A Hickman catheter was placed via the right subclavian vein and reinduction chemotherapy was started within 24 h onward the sixth postoperative day, the Hickman catheter record site became painful and drained clear fluid. Empiric broad-spectrum antibiotic coverage was started, and when the civilizations grew Aspergillus, amphotericin B was added. Comput tomography of the chest showed alone mild soft-tissue edema around the pang The patient became febrile to 40 [degrees] C and the catheter was remov The tip agricultures grew Aspergillus flavus. An eschar fence abouted by induration developed at the catheter minute site and was surgically excised to normal-appearing pectoral muscle fascia. Microscopic examination revealed vascular invasion through Aspergillus. A magnetic resonance imaging application of mind done to investigate right arm swelling showed that the right internal jugular, subclavian, and innominate veins were occlud and contained thrombus. strait-laced continued marrow suppression precluded anticoagulation, lytic therapy, or thrombectomy.
The patient remained febrile, neutropenic, and thrombocytopenic. Nonoliguric renal failure bring outed requiring dialysis. He then underwent a bone marrow transplantation. Meanwhile, further damage deterioration occurred, requiring debridements that remov portions of the right pectoralis major and minor muscles, intercostal muscles, and tissue around the subclavian canals Histologic study confirmed the appearance of invasive Aspergillus in the debrided tissue. These efforts at sway resulted in a large fault of skin, subcutaneous tissues, and muscle extending from the clavicle to the nipple, and from the anterior axillary line to just to the right of the breastbone with evidence of residual invasive Aspergillus at the margins, and in particular in a tract burrowing toward the subclavian utensils During this period, his platelet consider had slowly recovered to 50000 and he had received a total of 25 g of amphotericin B cultivations of pleural fluid were negative, and comput tomography of the head was normal. onward May 1, an operation was undertaken to excise all potentially infected tissue. A vertical cervical incision along the anterior border of the right sternocleidomastoid muscle was dilateed over the head of the clavicle, then curv laterally to note the open wound. The internal jugular vein was expos high in the neck ligated, and divided above the apparent flat of thrombosis. Rapid section histologic consideration showed no evidence of fungal invasion at the flush of division. A further incision was made from the head of the clavicle caudad from one side of to the other the costosternal junction to the third interspace, then laterally to the anterior axillary line, and carried satiated thickness through the chest wall. Findings included diffusely edematous, inflamed tissues, with thrombos proximal internal jugular, subclavian, and innominate veins. Rapid section histologic studies showed Aspergillus in the subclavian vein thrombus and vein wall, on the other hand not present in perivascular tissue. The abnormal appearing chest wall, to include the medial half of the clavicle, the anterior portions of the first and other ribs, and their costosternal cartilages and associated yielding tissues were excised. The subclavian vein was divided medial (closer obvious thrombus. The innominate vein was divided medial (closer to the superior vena cava) to thrombus. Reconstruction consisted of pectoralis major muscle flaps and skin grafting.
Postoperatively, the patient remained febrile, further with no other signs of ongoing sepsis. Further studies to include transesophageal echocardiography and abdominal comput tomography showed no evidence of residual foci of infection. Amphotericin B therapy was continued to a total dose of 3 g Bone marrow studies indicated continued remission, and at the close of the end of thefirst postoperative month the flushs resolved and he was discharged from the hospital.
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