American Journal of Clinical Dermatology

, Volume 7, Issue 1, pp 31–43

Cutaneous Fungal Infections in the Oncology Patient

Recognition and Management
  • Steven R. Mays
  • Melissa A. Bogle
  • Gerald P. Bodey
Therapy In Practice
  • 182 Downloads

Abstract

There are two main types of fungal infections in the oncology patient: primary cutaneous fungal infections and cutaneous manifestations of fungemia. The main risk factor for all types of fungal infections in the oncology patient is prolonged and severe neutropenia; this is especially true for disseminated fungal infections. Severe neutropenia occurs most often in leukemia and lymphoma patients exposed to high-dose chemotherapy. Fungal infections in cancer patients can be further divided into five groups: (i) superficial dermatophyte infections with little potential for dissemination; (ii) superficial candidiasis; (iii) opportunistic fungal skin infections with distinct potential for dissemination; (iv) fungal sinusitis with cutaneous extension; and (v) cutaneous manifestations of disseminated fungal infections. In the oncology population, dermatophyte infections (i) and superficial candidiasis (ii) have similar presentations to those seen in the immunocompetent host. Primary cutaneous mold infections (iii) are especially caused by Aspergillus, Fusarium, Mucor, and Rhizopus spp. These infections may invade deeper tissues and cause disseminated fungal infections in the neutropenic host. Primary cutaneous mold infections are treated with systemic antifungal therapy and sometimes with debridement. The role of debridement in the severely neutropenic patient is unclear. In some patients with an invasive fungal sinusitis (iv) there may be direct extension to the overlying skin, causing a fungal cellulitis of the face. Aspergillus, Rhizopus, and Mucor spp. are the most common causes. We also describe the cutaneous manifestations of disseminated fungal infections (v). These infections usually occur in the setting of prolonged neutropenia. The most common causes are Candida, Aspergillus, and Fusarium spp. Therapy is with systemic antifungal therapy. The relative efficacies of amphotericin B, fluconazole, itraconazole, voriconazole, and caspofungin are discussed. Recovery from disseminated fungal infections is unlikely, however, unless the patient’s neutropenia resolves.

References

  1. 1.
    Brown AE. Overview of fungal infections in cancer patients. Semin Oncol. 1990; 17 (3): 2–5Google Scholar
  2. 2.
    Morrison VA, Haake RJ, Weisdorf DJ. The spectrum of non-Candida fungal infections following bone marrow transplantation. Medicine. 1993; 72 (2): 78–89PubMedCrossRefGoogle Scholar
  3. 3.
    Nosari A, Oreste P, Cairoli R, et al. Invasive aspergillosis in hematological malignancies: clinical findings and management for intensive chemotherapy completion. Am J Hematol. 2001; 68: 231–6PubMedCrossRefGoogle Scholar
  4. 4.
    Stein DK, Sugar AM. Fungal infections in the immunocompromised host. Diagn Microbiol Infect Dis. 1989; 12: 221S–8SPubMedCrossRefGoogle Scholar
  5. 5.
    Grossman ME. Cutaneous manifestations of infection in the immunocompromised host. Baltimore (MD): Williams & Wilkins, 1995: 62–7Google Scholar
  6. 6.
    Wolfson JS, Sober AJ, Rubin RH. Dermatologic manifestations of infections in immunocompromised patients. Medicine. 1985; 64 (2): 115–33PubMedCrossRefGoogle Scholar
  7. 7.
    Bodey GP, Boktour M, Mays S, et al. Skin lesions associated with Fusarium infection. J Am Acad Dermatol. 2002; 47: 659–66PubMedCrossRefGoogle Scholar
  8. 8.
    Nucci M, Anaissie E. Cutaneous infections by Fusarium species in healthy and immunocompromised hosts: implications for diagnosis and management. Clin Infect Dis. 2002; 35: 909–20PubMedCrossRefGoogle Scholar
  9. 9.
    Tosti A, Piraccini BM, Lorenzi S. Onychomycosis caused by nondermatophyte molds: clinical features and response to treatment of 59 cases. J Am Acad Dermatol. 2000; 42 (2): 217–24PubMedCrossRefGoogle Scholar
  10. 10.
    Grossman ME. Cutaneous manifestations of infection in the immunocompromised host. Baltimore (MD): Williams & Wilkins, 1995: 188Google Scholar
  11. 11.
    Alto MD, Miller J, Townsend T, et al. Primary cutaneous aspergillosis associated with Hickman intravenous catheters. N Engl J Med. 1987; 317: 1105–8CrossRefGoogle Scholar
  12. 12.
    Walmsley S, Devi S, King S, et al. Invasive Aspergillus infections in a pediatric hospital: a ten year review. Pediatr Infect Dis J. 1993; 12: 673–82PubMedCrossRefGoogle Scholar
  13. 13.
    McCarty JM, Flam MS, Pullen G, et al. Outbreak of primary cutaneous aspergillosis related to intravenous arm boards. J Pediatr. 1986; 108: 721–4PubMedCrossRefGoogle Scholar
  14. 14.
    Abbasi S, Shenep JL, Hughes WT, et al. Aspergillosis in children with cancer: a 34 year experience. Clin Infect Dis. 1999; 29: 1210–9PubMedCrossRefGoogle Scholar
  15. 15.
    Sheldon DL, Johnson WC. Cutaneous mucormycosis: two documented cases of suspected nosocomial cause. JAMA. 1978; 241: 1032–4CrossRefGoogle Scholar
  16. 16.
    Gartenberg G, Bottone EJ, Keusch GT, et al. Hospital-acquired mucormycosis (Rhizopus rhizopodoformis) of skin and subcutaneous tissue. N Engl J Med. 1978; 299 (20): 1115–8PubMedCrossRefGoogle Scholar
  17. 17.
    Hammond DE, Winkelmann RK. Cutaneous phycomycosis: report of three cases with identification of Rhizopus. Arch Dermatol. 1979; 115: 990–2PubMedCrossRefGoogle Scholar
  18. 18.
    Everett ED, Pearson S, Rogers W. Rhizopus surgical wound infection associated with elasticized adhesive tape dressings. Arch Surg. 1979; 114: 738–9PubMedCrossRefGoogle Scholar
  19. 19.
    Wirth F, Perry R, Eskenazi A, et al. Cutaneous mucormycosis with subsequent visceral dissemination in a child with neutropenia. J Am Acad Dermatol. 1996; 35: 336–41CrossRefGoogle Scholar
  20. 20.
    Weitzman I. Saprophytic molds as agents of cutaneous and subcutaneous infection in the immunocompromised host. Arch Dermatol. 1986; 122: 1161–8PubMedCrossRefGoogle Scholar
  21. 21.
    Boutati E, Anaissie E. Fusarium, a significant emerging pathogen in patients with hematologic malignancy. Blood. 1997; 3: 999–1008Google Scholar
  22. 22.
    Iwen PC, Rupp ME, Hinrichs SH. Invasive mold sinusitis: 17 cases in immunocompromised patients and review of the literature. Clin Infect Dis. 1997; 24: 1178–84PubMedCrossRefGoogle Scholar
  23. 23.
    de Shazo RD, O’Brien M, Chapin K, et al. A new classification and diagnostic criteria for invasive fungal sinusitis. Arch Otolaryngol Head Neck Surg. 1997; 123: 1181–8CrossRefGoogle Scholar
  24. 24.
    Mandell GL, Bennett JE, Dolin R. Principles and practice of infectious disease. Philadelphia (PA): Churchill Livingstone, 2000: 2679–2687Google Scholar
  25. 25.
    Ferry AP, Abedi S. Diagnosis and management of rhino-orbital mucormycosis. Ophthalmology. 1983; 90: 1096–104PubMedGoogle Scholar
  26. 26.
    Moss ALH. Rhinocerebral mucormycosis. Ann Plast Surg. 1982; 9 (5): 431–5PubMedCrossRefGoogle Scholar
  27. 27.
    Howells RC, Ramadan HH. Usefulness of computed tomography and magnetic resonance in fulminant invasive fungal rhinosinusitis. Am J Rhinol. 2001; 15 (4): 255–61PubMedGoogle Scholar
  28. 28.
    Del Gaudio JM, Swain RE, Kingdom TT, et al. Computed tomographic findings in patients with invasive fungal sinusitis. Arch Otolaryngol Head Neck Surg. 2003; 129 (2): 236–40Google Scholar
  29. 29.
    Dignani MC, Anaissie E. Human fusariosis. Clin Microbiol Infect. 2004; 10 Suppl. 1: 67–75PubMedCrossRefGoogle Scholar
  30. 30.
    Rolston K. Overview of systemic fungal infections. Oncology (Williston Park). 2001 Nov; 15 (11 Suppl. 9): 11–4Google Scholar
  31. 31.
    Klimowski LL, Rotstein C, Cummings KM. Incidence of nosocomial aspergillosis in patients with leukemia over a twenty year period. Infect Control Hosp Epidemiol. 1989; 10: 299–305PubMedCrossRefGoogle Scholar
  32. 32.
    Singh N, Paterson DL. Aspergillus infections in transplant recipients. Clin Microbiol Rev. 2005; 18: 44–69PubMedCrossRefGoogle Scholar
  33. 33.
    Pagano L, Antinori A, Ammassari A, et al. Retrospective study of candidemia in patients with hematologic malignancies: clinical features, risk factors and outcome of 76 episodes. Fur J Hematol. 1999; 63 (2): 77–85Google Scholar
  34. 34.
    Bodey GP, Luna M. Skin lesions associated with disseminated candidiasis. JAMA. 1979; 229: 1466–8CrossRefGoogle Scholar
  35. 35.
    Grossman ME, Silvers DN, Walther RR. Cutaneous manifestations of disseminated candidiasis. J Am Acad Dermatol. 1980; 2: 111–6PubMedGoogle Scholar
  36. 36.
    Meyer PD, Kaplan MH, Ong M, et al. Cutaneous lesions in disseminated mucormycosis. JAMA. 1973; 225 (7): 732–8CrossRefGoogle Scholar
  37. 37.
    Myskowski PL, Brown AE, Dinsmore R, et al. Mucormycosis following bone marrow transplantation. J Am Acad Dermatol. 1983; 9: 111–5PubMedCrossRefGoogle Scholar
  38. 38.
    Kramer BS, Hernandez AD, Reddick RL, et al. Cutaneous infarction: manifestation of disseminated mucormycosis. Arch Dermatol. 1977; 113: 1075–6PubMedCrossRefGoogle Scholar
  39. 39.
    Mandell GL, Bennett JE, Dolin R. Principles and practice of infectious disease. Philadelphia (PA): Churchill Livingstone, 2000: 2708Google Scholar
  40. 40.
    Grossman ME. Cutaneous manifestations of infection in the immunocompromised host. Baltimore (MA): Williams & Wilkins, 1995: 16Google Scholar
  41. 41.
    Grossman ME. Cutaneous manifestations of infection in the immunocompromised host. Baltimore (MA): Williams & Wilkins, 1995: 58Google Scholar
  42. 42.
    Walsh TJ. Trichosporonosis. Infect Dis Clin North Am. 1989; 3: 43–5PubMedGoogle Scholar
  43. 43.
    Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis: Infectious Diseases Society of America. Clin Infect Dis. 2004 Jan 15; 38 (2): 161–89PubMedCrossRefGoogle Scholar
  44. 44.
    Stevens DA, Kan VL, Judson MA, et al. Practice guidelines for diseases caused by Aspergillus: Infectious Diseases Society of America. Clin Infect Dis. 2000; 30 (4): 696–709PubMedCrossRefGoogle Scholar
  45. 45.
    Saag MS, Graybill RJ, Larsen RA, et al. Practice guidelines for the management of cryptococcal disease: Infectious Diseases Society of America. Clin Infect Dis. 2000; 30 (4): 710–8PubMedCrossRefGoogle Scholar
  46. 46.
    Bodey GP. Candidiasis in cancer patients. In: Bodey GP, editor. Candidiasis: a growing concern. Am J Med 1984; 77 (4D): 13–9PubMedGoogle Scholar
  47. 47.
    Goodrich JM, Reed E, Mori M, et al. Clinical factors and analysis of risk factors for invasive candidal infection after marrow-transplantation. J Infect Dis. 1991; 164: 731–40PubMedCrossRefGoogle Scholar
  48. 48.
    Anaissie E, White M, Uzon O, et al. Amphotericin B lipid complex (ABLC) versus amphotericin B for treatment of hematogenous and invasive candidiasis: a prospective, randomized, multicenter trial [abstract]. Program and abstracts of the Interscience Conference on Antimicrobial Agents and Chemotherapy. Washington, DC: American Society for Microbiology, 1995: 330Google Scholar
  49. 49.
    Kontoyiannis DP, Bodey GP, Mantzoros CS. Fluconazole vs amphotericin B for the management of candidaemia in adults: a meta-analysis. Mycoses. 2001; 44: 125–35PubMedCrossRefGoogle Scholar
  50. 50.
    Rex JH, Pappas PG, Karchmer AW, et al. A randomized and blinded multicenter trial of high-dose Fuconazole (F) + placebo (P) vs F + amphotericin B (A) as treatment of candidemia in non-neutropenic patients [abstract no. J-681 a]. 41st Interscience Conference on Antimicrobial Agents and Chemotherapy; 2001 Sep 22–25; Chicago (IL), 378Google Scholar
  51. 51.
    Mora-Duarte J, Betts R, Coleman R, et al. Comparison of caspofungin and amphotericin B for invasive candidiasis. N Engl J Med. 2003; 347 (25): 2020–9CrossRefGoogle Scholar
  52. 52.
    Herbrecht R, Denning DW, Patterson TF, et al. Voriconazole versus amphotericin B for primary therapy of invasive aspergillosis. N Engl J Med. 2002; 347 (6): 408–15PubMedCrossRefGoogle Scholar
  53. 53.
    Ellis M, Spence D, DePauw B, et al. An EORTC international multicenter randomized trial (EORTC number 19923) comparing two dosages of liposomal amphotericin B for treatment of invasive aspergillosis. Clin Infect Dis. 1998; 27: 1406–12PubMedCrossRefGoogle Scholar
  54. 54.
    Letscher-Bru V, Herbrecht R. Caspofungin: the first representative of a new antifungal class. J Antimicrob Chemother. 2003; 51: 513–21PubMedCrossRefGoogle Scholar
  55. 55.
    Baddley JW, Pappas PG. Antifungal combination therapy: clinical potential. Drugs 2005; 65 (11): 1461–80PubMedCrossRefGoogle Scholar
  56. 56.
    Antoniadou A, Kontoyiannis DP. Status of combination therapy for refractory mycoses. Curr Opin Infect Dis. 2003; 16: 539–45PubMedCrossRefGoogle Scholar
  57. 57.
    Gupta SK, Sarosis GA. Cryptococcal meningitis. Curr Treat Options Infect Dis. 2002; 4: 403–511Google Scholar
  58. 58.
    Larsen RA, Bozzette SA, Jones BE, et al. Fluconazole combined with flucytosine for treatment of cryptococcal meningitis in patients with AIDS. Clin Infect Dis. 1994; 19: 741–5PubMedCrossRefGoogle Scholar
  59. 59.
    Anaissie E, Gokaslan A, Hachem R, et al. Azole therapy for trichosporonosis: clinical evaluation of eight patients, experimental therapy of murine infection, and review of the literature. Clin Infect Dis. 1992; 15: 781–7PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2006

Authors and Affiliations

  • Steven R. Mays
    • 1
    • 2
  • Melissa A. Bogle
    • 1
  • Gerald P. Bodey
    • 3
  1. 1.Department of DermatologyUniversity of Texas Medical SchoolHoustonUSA
  2. 2.Department of DermatologyUniversity of Texas M.D. Anderson Cancer CenterHoustonUSA
  3. 3.Department of Infectious DiseaseUniversity of Texas M.D. Anderson Cancer CenterHoustonUSA

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