Correspondence

Destruction of the Nasal Septum by Aspergillus Infection after Autologous Bone Marrow Transplantation

N Engl J Med 1997; 337:275-276July 24, 1997

Article

To the Editor:

We report the case of a 15-year-old boy with necrosis of the nasal septum due to aspergillus infection after autologous bone marrow transplantation for acute myelogenous leukemia. Treatment must often be initiated before a definitive diagnosis is made, given the potentially serious, even fatal, consequences of delayed therapy.

Five weeks after bone marrow transplantation, the patient still had severe neutropenia, with an absolute neutrophil count of 3 per cubic millimeter. He had daily fevers and painful swelling of his upper lip and paranasal areas (Figure 1Figure 1Upper-Lip and Central Facial Swelling after Autologous Bone Marrow Transplantation in a 15-Year-Old Boy.). He did not have a headache or nasal drainage. The facial swelling was not erythematous or warm, and the patient had no visible skin or mucosal lesions. Blood, throat, nasal, urine, and stool cultures were obtained, and treatment with ceftazidime and gentamicin was started. Plain sinus films showed no sinusitis. Because the fevers and tender facial swelling persisted, on day 3, the antibiotic therapy was changed to a combination of imipenem, gentamicin, vancomycin, and acyclovir. On day 4, amphotericin was added.

On day 7, the results of a sinus evaluation by computed tomography were normal. A 4-mm punch-biopsy specimen of the posterior surface of the swollen upper lip revealed edema; fungal, bacterial, and viral cultures were negative. By day 10, the fevers had ceased, but the tender facial swelling persisted. Otolaryngologic evaluation revealed a small septal perforation. On day 18, injections of granulocyte colony-stimulating factor were initiated.

On day 25, with an absolute neutrophil count of 350 per cubic millimeter, the patient noticed a hard swelling in his nose. An irregular, firm, gray–white mass, 2 cm by 3 cm, in the anterior-inferior nasal septum was easily dislodged, leaving a large nasal septal defect. Pathological examination of the specimen revealed extensive necrosis, acute inflammation, and numerous septate hyphae — findings consistent with aspergillus infection (Figure 2Figure 2Biopsy Specimen of the Necrotic Mass in the Nasal Cavity (Methenamine Silver Stain, ×160).). Culture of the specimen yielded Aspergillus flavus; viral and bacterial cultures were negative. The facial swelling gradually improved with amphotericin therapy. One year later, the boy was doing well.

Invasive fungal infections cause substantial morbidity and mortality in patients after bone marrow transplantation.1 Prolonged neutropenia, severe immunosuppression, and treatment with broad-spectrum antibiotics2-4 put our patient at risk for invasive nasal aspergillosis. A. flavus is the most common pathogen.1 Initial signs are often subtle3 but typically include fever and tender facial swelling,1,4 as in our patient. Standard treatment includes therapy with amphotericin B and débridement of affected tissues.1,2 Patients may benefit from granulocyte transfusions1 or correction of neutropenia with granulocyte colony-stimulating factor.5 The potentially serious consequences of progressive disease1,2 underscore the need for prompt diagnosis and treatment.

George K. Siberry, M.D., M.P.H.
Constantino Costarangos, M.D.
Bernard A. Cohen, M.D.
Johns Hopkins University School of Medicine, Baltimore, MD 21205

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Citing Articles (3)

Citing Articles

1. 1

   Fouzia Naeem, Jeffrey E. Rubnitz, Hana Hakim. (2011) Isolated Nasal Septum Necrosis Caused by Aspergillus flavus in an Immunocompromised Child. The Pediatric Infectious Disease Journal 30:7, 627-629
   CrossRef

2. 2

   Jerome B. Taxy. (2006) Paranasal Fungal Sinusitis: Contributions of Histopathology to Diagnosis. The American Journal of Surgical Pathology 30:6, 713-720
   CrossRef

3. 3

   David L. Paterson, Nina Singh. (1999) Invasive Aspergillosis in Transplant Recipients. Medicine 78:2, 123-138
   CrossRef