June 3, 2014 Grand Rounds

Case 1: Invasive Aspergillus sphenoid sinusitis associated with cavernous sinus thrombosis in a patient with lymphoma receiving chemotherapy

1. The discussion centered on the use of combination antifungal therapy for invasive mold infection. The bottom-line is that, although there is no good data to support the routine use of combination antifungal therapy, no antagonism in vivo and in vitro is seen between different antifungal combinations, especially with that of amphotericin plus an echinocandin. A good review is found here.


Case 2: Acute generalized exanthematous pustulosis (AGEP) secondary to a brown recluse spider bite in a 5-year old immunocompetent child

1. Always keep brown recluse spider bite in your differential diagnosis for somebody who presents with a localized cellulitis that is associated with fever and Coombs-positive hemolytic anemia. The bite of the brown recluse spider does not always have to be obvious. It may sometimes appear as a localized swelling without an eschar. Severe cases can also lead to multi-organ failure and DIC (systemic loxoscelism). A good review is found here.


2. AGEP should always be entertained in the differential diagnosis of diffuse pustular rash associated with fever. The most common cause is exposure to certain medications. Rarely, it can be caused by spider bites. Certain viral infections have also been shown to cause AGEP, including adenovirus, parvovirus B19, enterovirus, hepatitis B, hepatitis C, EBV, and CMV. AGEP can mimic other serious dermatologic conditions including pustular psoriasis of von Zumbusch, Behcet's disease, DRESS, and SJS/TEN. A good review is found here.


Case 3: Scedosporium pulmonary infection in a neutropenic patient

1. All Scedosporium sp. are universally resistant to amphotericin. The drug of choice is voriconazole.

2. Scedosporium prolificans is a nasty fungus. It is known to be resistant to almost all antifungals. Treatment success has been reported with the use of voriconazole plus terbinafine.

3. A "buzzword" for Scedosporium infection among immunocompetent hosts is "near-drowing" since several infections with this fungus have been documented among patients with near-drowning experience.