Counting Spores: A Case of Mixed Fungal Infection- Candidal Ecthyma Gangrenosum and Invasive Pulmonary Aspergillosis in a Patient With Acute Myeloid Leukemia

Introduction: Invasive fungal infections comprise a group of diseases affecting deep-seated tissues, with the most common etiologic agents being Candida and Aspergillus species. These are associated with high morbidity and mortality. Populations commonly affected are those in immunocompromised states, including patients with hematologic malignancies. Mixed fungal infections may co-occur, presenting with nonspecific symptoms making diagnosis and management complicated.  
 
Case Report: A 55-year-old female diagnosed with leukemia, underwent chemotherapy and later on developed febrile neutropenia. During her admission, she had progressive pneumonia even after multiple intravenous antibiotics. Due to clinical deterioration, she was transferred to the intensive care unit and underwent bronchoscopy. Tests for tuberculosis, bacteria, and viruses yielded negative results. Lavage galactomannan tested positive (index of 8.01) and fungal culture showed growth of Aspergillus species. She was started on isavuconazole for invasive pulmonary aspergillosis. At the same time, crusting nasal lesions were observed, with samples testing positive for both Aspergillus and Candida. Isavuconazole was continued for Candida ecthyma gangrenosum, with symptom resolution.  
 
Conclusion: In immunocompromised patients, a high-index of suspicion for invasive fungal diseases should be observed. Leukemia presents with an innate immune dysfunction aggravated by neutropenia, placing patients at higher risk. They may present with nonspecific symptoms causing delays in diagnosis and treatment initiation. Mixed fungal infections may inflict patients, further posing challenges to management. As these have high mortality risk, antifungals may be started alongside diagnostic evaluation - the choice of which, tailored to the patient’s clinical profile. Timely diagnosis and treatment will be tantamount to their survival.

Emmanuel Mamaril is an ardent learner, taking up his Internal Medicine residency in the Philippines. He has a bachelor of science in biology, and attained his medical degree in Ateneo School of Medicine and Public Health. He is an aspiring infectious disease specialist who has the willingness to learn about and explore the world of infectious diseases. He enjoys reading articles and cases involving infectious diseases. Outside work, he enjoys chill days at the beach, hanging out with friends, and spending quality time with family. He hopes to be a medical specialist capable of inciting good changes in public health