Clinical Data

Over the last decades, efforts to reconstitute host defence with granulocyte transfusion therapy have increased after the advances of the availability of recombinant hematopoietic growth factors and modern transfusion practices. In severely neutropenic patients suffering from fusariosis, treatment with G- or GM-CSF and granulocyte transfusions may also be considered (Dignani et al., 1997; Boutati & Anaissie, 1997; Price et al., 2000; Rutella et al., 2003; Durand-Joly et al., 2003) (Table 12.1). The beneficial effect of the transfusions seems to be enhanced by their administration to patients with good performance status as well as by their administration early during neutropenia and soon after onset of fusariosis.

The principle of therapy in fusariosis is early aggressive treatment with high doses of amphotericin B. When fusariosis is refractory to standard antifungal therapy or the patient does not tolerate therapy, amphotericin B can switch to a new tria-zole. In addition, G-CSF or GM-CSF plus granulocyte transfusion can be potential adjuvant therapeutic strategies combined with catheter removal (if the catheter is the source of fusariosis) and debridement of devitalized tissue (in localized disease). Long duration of antifungal treatment is crucial and has to be individualized for the better outcome of the patient.

The current clinical evidence on the role of antifungals and immunomodula-tory factors in the host response against scedosporiosis is limited, involving mainly haematopoietic growth factors and IFN. Noteworthy, of the 39 cases reported in the literature with disseminated Scedosporium spp. infection, favourable outcome was reported only in four of them (Guarro et al., 2006). In these cases the positive outcome was attributed to the immunomodulatory factors administered in addition to antifungal drugs whereas the true role of antifungals was difficult to be established (Munoz et al., 2000; Girmenia et al., 1998; Ochiai et al., 2003; Phillips et al., 1991). Undoubtedly, the outcome of antifungal therapy

Table 12.1 Use of granulocyte transfusions in the treatment of fusariosis and scedosporiosis

Reference

Underlying condition

No of patients

Outcome

Minor et al. (1989)

Bone marrow

2

0/2 Responses

transplantation

Barrios et al. (1990)

Bone marrow

1

1/1 Complete response

transplantation

Helm et al. (1990)

Acute lymphocytic

1

1/1 Complete response

leukemia

Spielberger

Pancytopenia

1

1/1 Complete response

et al. (1994)

Dignani et al. (1997)

Neutropenia

3

2/3 Complete response

Boutati and

Hematological

7a

3/7 Complete response

Anaissie (1997)

malignancies

Girmenia et al. (1999)

Severe aplastic anemia

1a

0/1 Cesponse

Price et al. (2000)

Stem cell transplant

2

0/2 Responses

Rutella et al. (2003)

Hematological

1

1/1 Complete response

malignancies,

neutropenia

Durand-Joly

B-acute leukemia

1a

1/1 Complete response

et al. (2003)

Total

19

10/19 Complete response

a Granulocyte transfusions after stimulation with G-CSF.

a Granulocyte transfusions after stimulation with G-CSF.

alone in scedosporiosis is poor with high overall mortality rates, and cases that have been initially treated with amphotericin B have been dismal (Guarro et al., 2006). Among the promising antifungals is voriconazole, though the results are still contradictory (Walsh et al., 2002; Perfect et al., 2003). Due to the multidrug resistance a crucial point in the management of scedosporiosis is immune function reconstitution. Characteristically, only 2 out of 16 patients infected with S. prolificans survived and their survival coincided with hematologic recovery (Berenguer et al., 1997). Similarily, in another review disseminated S. prolificans infection was fatal in all neutropenic patients (Revankar et al., 2002).

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