Blood, Vol. 91 No. 8 (April 15), 1998:
pp. 3087-3089
CORRESPONDENCE
Hepatic Lesions of Chronic Disseminated Systemic Candidiasis in
Leukemia Patients May Become Visible During Neutropenia: Value of
Serial Ultrasound Examinations
 |
LETTER |
To the Editor:
In a recent issue of Blood, Pestalozzi et al1
reported interesting data on computerized tomographic
(CT)-scan examinations in chronic systemic candidiasis in leukemia
patients that become invisible during neutropenia. CT-scan is known to
be sensitive, as has been demonstrated for magnetic resonance imaging
(MRI)-scan.2,3 However, only ultrasound can be
repeated as often as needed. Data correlation to ultrasound findings in
these patients are lacking. Ultrasound examinations are easy to
perform, comfortable for the patient, and cost-effective. We have
analyzed prospectively the value of serial ultrasound examination in
the diagnosis and follow-up of chronic systemic candidiasis in leukemia
patients.4 From November 1996 until October 1997, a total
of 220 ultrasound examinations (Kranzbühler Logiq 500, 3.5 MHz-convex array; Solingen, Germany) were performed in 58 leukemia
patients undergoing intensive chemotherapy. Initial
ultrasound pictures were stored on a personal computer and compared
with the live ultrasound at the time of re-evaluation in cases of
persistent fever. Abdominal ultrasound detected microabscesses in 8 patients. Diagnosis was confirmed by autopsy/biopsy (n = 6), blood
culture (n = 1), and a significant candida-antibody titer at the time
of neutrophil recovery (n = 1). According to Pestalozzi et
al,1 focal lesions representing microabscesses in liver or
spleen were detected by ultrasound only after neutrophil recovery. None
of our serially monitored patients (ranging from 1 to a maximum of 16 follow-up examinations) showed a disappearance of hepatic lesions
within subsequent phases of aplasia with a reappearance after recovery
of the neutrophil count. We point out that our experiences with
ultrasound are different from the observed CT-scans in the study of
Pestalozzi et al.1 Based on our data, we believe that
ultrasound examinations should be performed in addition to CTscan,
because this might provide helpful complementary information.
In addition to the reported CT-scan findings, a nonhomogenous
micronodular parenchyma reflex pattern of liver and/or spleen was observed by ultrasound as a first sign in two of three patients who
subsequently developed focal lesions, which persisted during febrile
neutropenia (Table 1). A third patient
developed a nonhomogenous parenchyma reflex pattern in the liver
without evolving focal lesions subsequently. This patient had a proven
septicemia with candida tropcalis and died in aplasia. A changing
reflex pattern of the liver parenchyma has been also reported by Grois
et al5 as a first sign in the course of chronic systemic
candidiasis; however, this is not proven to be specific. New evolving
focal lesions (wheel-in-wheel sign) in liver or spleen of small
diameter are known to be ultrasound characteristics in chronic systemic candidiasis.6,7 Ultrasound proved to be as sensitive as
CT-scan to detect these lesions in our study. Focal lesions detected in the liver and spleen ranged from 5 to 19 mm in diameter. The incidence of chronic systemic candidiasis was 13.8% in our study group, comparable to data in the literature.5,8 Because ultrasound was sensitive, follow-up of these patients with chronic systemic candidiasis was performed using ultrasound alone. One possible disadvantage of ultrasound examinations is a lack of sufficient documentation in serial ultrasound. However, we improved the
reliability of ultrasound by computer-assisted documentation. Follow-up
was easy to perform, because ultrasound pictures could be compared directly with live examinations on the screen (Fig
1).
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| Fig 1.
The ultrasound pictures of this patient show a
nonresponse to antifungal therapy in the course of chronic systemic
candidiasis. The micro-abscesses in the left lobe of the liver are
documented to be nonresponding. All stored ultrasound pictures, in part
demonstrated on the left side of the computer screen, can be enlarged
for comparison.
|
|
In conclusion, we would recommend ultrasound examination in all
patients with suspected or proven chronic systemic candidiasis, especially in those cases in which the lesions become invisible by
CT-scans. In addition, a change in the parenchyma reflex pattern of
liver and/or spleen during febrile neutropenia might be the first manifestation of an evolving chronic systemic candidiasis. Ultrasound proved to be sensitive and effective for the detection and
follow-up of patients with chronic systemic candidiasis. Finally, ultrasound is comfortable for the patient and
cost-effective.
M. Karthaus
G. Huebner
R.G. Geissler
G. Heil
A. Ganser
Department of Haematology and
Oncology
Hannover Medical School
Hannover, Germany
| |
REFERENCES |
1.
Pestalozzi BC,
Krestin GP,
Schanz U,
Jacky E,
Gmür J:
Hepatic lesions of chronic disseminated candidiasis may become invisible during neutropenia.
Blood
90:3858,
1997[Abstract/Free Full Text]
2.
Thaler M,
Pastakia B,
Shawker TH,
O'Leary T,
Pizzo PA:
Hepatic candidiasis in cancer patients: The evolving picture of the syndrome.
Ann Intern Med
108:88,
1988
3.
von Eiff M,
Essink M,
Roos N,
Hiddemann W,
Buchner T,
van de Loo J:
Hepatosplenic candidiasis, a late manifestation of Candida septicaemia in neutropenic patients with haematologic malignancies.
Blut
60:242,
1990[Medline]
[Order article via Infotrieve]
4. Karthaus M, Elser C, Meran JG, Huebner G, Heil G, Ganser G:
Detection of hepatosplenic candidiasis in febrile
neutropenia
Incidence and features in ultrasound examinations.
Toronto, Ontario, Canada, Proceedings 37th ICCAC, 368(LM-23a), 1997 (abstr)
5.
Grois N,
Mostbeck G,
Scherrer R,
Chott A,
Schwarzinger I,
Muhm M,
Bettelheim P,
Forstinger C,
Laczika K,
Kyrle PA,
Lechner K:
Hepatic and splenic abscessesA common complication of intensive chemotherapy of acute myeloid leukemia (AML).
Ann Hematol
63:33,
1991[Medline]
[Order article via Infotrieve]
6.
Gorg C,
Weide R,
Schwerk WB,
Koppler H,
Havemann K:
Ultrasound evaluation of hepatic and splenic microabscesses in the immunocompromised patient: Sonographic patterns, differential diagnosis, and follow-up.
J Clin Ultrasound
22:525,
1994[Medline]
[Order article via Infotrieve]
7.
Karthaus M,
Meier NP,
Manns MP,
Ganser A,
Hertenstein B:
Hepatische Komlikationen bei Stammzellstransplantationen (Hepatic complications of stem cell transplantation).
Dtsch Med Wochenschr
122:1154,
1997[Medline]
[Order article via Infotrieve]
8.
Blade J,
Lopez Guillermo A,
Rozman C,
Granena A,
Bruguera M,
Bordas J,
Cervantes F,
Carreras E,
Sierra J,
Montserrat E:
Chronic systemic candidiasis in acute leukemia.
Ann Hematol
64:240,
1992[Medline]
[Order article via Infotrieve]
