Infectious Diseases and Supportive Care
Infectious Diseases and Supportive Care
Lortholary O, Ascioglu S, Moreau P, et al.
Clin Infect Dis. 2000;30:41-46.
In this study, we report on the incidence and characteristics of invasive aspergillosis in patients with multiple myeloma who did not receive an allograft and who were treated at hematology or oncology centers in Europe from 1984 to 1996. Of a total of 31 patients identified, 21 (68%) met the criteria for definitive invasive aspergillosis, and 10 (32%) met the criteria for probable invasive aspergillosis. Of the 31 cases, 23 (74%) were reported between 1992 and 1996. Twenty-nine cases (94%) of invasive aspergillosis occurred in patients with Durie-Salmon stage 3 multiple myeloma, and 2 cases (6%) occurred in patients with Durie-Salmon stage 2 multiple myeloma. The median time between diagnosis of multiple myeloma and diagnosis of invasive aspergillosis was 8 months (range, 1 to 75 months). Sixteen patients (52%) had a neutrophil count of less than or equal to 500/µL for a median duration of 19 days (range, 10 to 37 days). Fourteen patients (45%) had recently received corticosteroid therapy, and 11 patients (36%) had received high doses of melphalan. Twenty-eight patients had primary pulmonary invasive aspergillosis, and 3 had primary sinus invasive aspergillosis. Death in 45% of the patients was attributed to this opportunistic fungal infection.
We conclude that patients with myeloma who do not receive allografts but who are treated intensively are at higher risk for developing a potentially lethal invasive opportunistic infection with Aspergillus.
Editorial Comment by John N. Greene, MD
Key words:
Multiple myeloma is increasing in incidence as our population ages. In response, we have been seeing a trend toward more intensive chemotherapy followed by allogeneic bone marrow transplantation, or autologous stem cell transplantation and high doses of steroids. Because of the resultant prolonged neutropenia and increase in cell-mediated immune dysfunction from these treatment modalities, invasive aspergillosis is expected to increase among multiple myeloma patients. This article reports on more than a decade of experience with European patients with multiple myeloma who developed invasive aspergillosis.
Advanced multiple myeloma (Durie-Salmon stage 3) was present in 94% of cases with a median time of 8 months between the diagnosis of multiple myeloma and invasive aspergillosis. Most patients had a period of prolonged neutropenia (greater than 14 days with a neutrophil count < 500/µL), and recent steroid use was found in 45%. Of 31 cases, 28 involved the lung and 3 the sinus, and the mortality rate was high. Forty-five percent of patients died from invasive aspergillosis.
This opportunistic fungal infection is a dreaded complication among patients who are immunosuppressed, with mortality rates ranging from 40% to 90% in select populations. Allogeneic bone marrow transplantation and hematologic malignancies with prolonged neutropenia resulting from intensive chemotherapy are the most common risk factors for susceptibility to invasive infection with Aspergillus.
Because of more intensive therapeutic regimens leading to improved survival, patients with multiple myeloma are now added to the list of those at high risk for invasive aspergillosis. Strategies to combat this growing problem include prolonged antifungal prophylaxis during periods of highest risk for invasive aspergillosis.
Agents with activity against molds, such as Aspergillus species, that could be used in this setting include lipid formulations of amphotericin B; itraconazole; echinocandins, which have been recently approved by the FDA; and voriconazole, which was recently submitted to the FDA for approval.
Use of high-efficiency particulate air filtration in the patient's environs during the period of neutropenia and judicious use of colony-stimulating factors are additional strategies to help prevent opportunistic infection by Aspergillus species.
This European study reminds us of how new, successful strategies to treat otherwise incurable disease, such as multiple myeloma, can result in new obstacles that must be overcome to achieve the goal of prolonged cancer-free survival.
Lortholary O, Ascioglu S, Moreau P, et al.
Clin Infect Dis. 2000;30:41-46.
In this study, we report on the incidence and characteristics of invasive aspergillosis in patients with multiple myeloma who did not receive an allograft and who were treated at hematology or oncology centers in Europe from 1984 to 1996. Of a total of 31 patients identified, 21 (68%) met the criteria for definitive invasive aspergillosis, and 10 (32%) met the criteria for probable invasive aspergillosis. Of the 31 cases, 23 (74%) were reported between 1992 and 1996. Twenty-nine cases (94%) of invasive aspergillosis occurred in patients with Durie-Salmon stage 3 multiple myeloma, and 2 cases (6%) occurred in patients with Durie-Salmon stage 2 multiple myeloma. The median time between diagnosis of multiple myeloma and diagnosis of invasive aspergillosis was 8 months (range, 1 to 75 months). Sixteen patients (52%) had a neutrophil count of less than or equal to 500/µL for a median duration of 19 days (range, 10 to 37 days). Fourteen patients (45%) had recently received corticosteroid therapy, and 11 patients (36%) had received high doses of melphalan. Twenty-eight patients had primary pulmonary invasive aspergillosis, and 3 had primary sinus invasive aspergillosis. Death in 45% of the patients was attributed to this opportunistic fungal infection.
We conclude that patients with myeloma who do not receive allografts but who are treated intensively are at higher risk for developing a potentially lethal invasive opportunistic infection with Aspergillus.
Editorial Comment by John N. Greene, MD
Key words:
Multiple myeloma
Neutropenia
Invasive aspergillosis
Multiple myeloma is increasing in incidence as our population ages. In response, we have been seeing a trend toward more intensive chemotherapy followed by allogeneic bone marrow transplantation, or autologous stem cell transplantation and high doses of steroids. Because of the resultant prolonged neutropenia and increase in cell-mediated immune dysfunction from these treatment modalities, invasive aspergillosis is expected to increase among multiple myeloma patients. This article reports on more than a decade of experience with European patients with multiple myeloma who developed invasive aspergillosis.
Advanced multiple myeloma (Durie-Salmon stage 3) was present in 94% of cases with a median time of 8 months between the diagnosis of multiple myeloma and invasive aspergillosis. Most patients had a period of prolonged neutropenia (greater than 14 days with a neutrophil count < 500/µL), and recent steroid use was found in 45%. Of 31 cases, 28 involved the lung and 3 the sinus, and the mortality rate was high. Forty-five percent of patients died from invasive aspergillosis.
This opportunistic fungal infection is a dreaded complication among patients who are immunosuppressed, with mortality rates ranging from 40% to 90% in select populations. Allogeneic bone marrow transplantation and hematologic malignancies with prolonged neutropenia resulting from intensive chemotherapy are the most common risk factors for susceptibility to invasive infection with Aspergillus.
Because of more intensive therapeutic regimens leading to improved survival, patients with multiple myeloma are now added to the list of those at high risk for invasive aspergillosis. Strategies to combat this growing problem include prolonged antifungal prophylaxis during periods of highest risk for invasive aspergillosis.
Agents with activity against molds, such as Aspergillus species, that could be used in this setting include lipid formulations of amphotericin B; itraconazole; echinocandins, which have been recently approved by the FDA; and voriconazole, which was recently submitted to the FDA for approval.
Use of high-efficiency particulate air filtration in the patient's environs during the period of neutropenia and judicious use of colony-stimulating factors are additional strategies to help prevent opportunistic infection by Aspergillus species.
This European study reminds us of how new, successful strategies to treat otherwise incurable disease, such as multiple myeloma, can result in new obstacles that must be overcome to achieve the goal of prolonged cancer-free survival.
Source...