Candida Infection During Successful Treatment of Mucor Infection Through Antifungal and Minimal Invasive Surgery in a Child with Acute Lymphoblastic Leukemia

İnvaziv mukormikozis nadir görülen ancak mortalitesi yüksek bir fungal enfeksiyondur. Sıklıkla diyabetik ketoasidozlu, hematolojik malignensili veya kök hücre transplantasyonu yapılan immünsüprese hastalarda görülmektedir. Akut lenfoblastik lösemi tanılı üç yaşında erkek hastada indüksiyon kemoterapisi sırasında febril nötropeni, sağ yanakta şişlik ve damakta nekrotize alan gelişti. İntranazal biyopsi örneğinde mukor hifaları görüldü. Minör debritmanlar ve antifungal tedavi uygulandı ve tedavinin altıncı ayında aynı bölgede sağ maksiller kemikte yumuşama saptandı. Biyopsi örneğinde Candida tropicalis üredi ve kombine antifungal ilaçlar ile tedavi edildi. Bu olgu mukor enfeksiyonunun majör cerrahi yapılmadan minör debritmanlar ve antifungal ilaçlar ile başarılı bir şekilde tedavi edilebileceğini ve geniş spektrumlu ve etkin antifungal ilaçlara rağmen breakthrough fungal enfeksiyonların da göz ardı edilmemesi gerektiğini vurgulamak amacıyla sunuldu.Invasive mucormycosis is a fungal infection that is rare but has a high mortality rate. It is often seen in immune supressed patients with diabetic ketoacidosis, hematologic malignancy, or those that have undergone stem cell transplantation. Febrile neutropenia, swelling of the right cheek, and a necrotic area in the palate developed during the induction chemotherapy of a three year-old male patient with acute lymphoblastic leukemia. Minor debridements and antifungal treatment was applied, and in the sixth month of the treatment, softening of the right maxillary bone was detected in the same area. From the biopsy sample, Candida tropicalis grew in the culture, and was treated with combined antifungal medicines. This case is presented to emphasize the feasibility of mucor infection treatment via minor debridements and antifungal medicines without any need for major surgery, and also to emphasize that breaktrough fungal infections should not be ignored, in spite of the antifungal medicines that are highly effective and have broad-spectrum

Thrombolysis with Systemic Recombinant Tissue Plasminogen Activator in Children: A Multicenter Retrospective Study

Objective: This study aimed to evaluate systemic thrombolysis experiences with recombinant tissue plasminogen activator (rtPA). Materials and Methods: Retrospective data were collected from 13 Turkish pediatric hematology centers. The dose and duration of rtPA treatment, concomitant anticoagulant treatment, complete clot resolution (CCR), partial clot resolution (PCR), and bleeding complications were evaluated. Low-dose (LD) rtPA treatment was defined as 0.01-0.06 mg/kg/h and high-dose (HD) rtPA as 0.1-0.5 mg/kg/h. Results: Between 2005 and 2019, 55 thrombotic episodes of 54 pediatric patients with a median age of 5 years (range: 1 day to 17.75 years) were evaluated. These patients had intracardiac thrombosis (n=16), deep vein thrombosis (DVT) (n=15), non-stroke arterial thrombosis (n=14), pulmonary thromboembolism (PE) (n=6), and stroke (n=4). The duration from thrombus detection to rtPA initiation was a median of 12 h (range: 2-504 h) and it was significantly longer in cases of DVT and PE compared to stroke, non-stroke arterial thrombosis, and intracardiac thrombosis (p=0.024). In 63.6% of the episodes, heparin was initiated before rtPA treatment. LD and HD rtPA were administered in 22 and 33 of the episodes, respectively. Concomitant anticoagulation was used in 90% and 36% of the episodes with LD and HD rtPA, respectively (p=0.0001). Median total duration of LD and HD rtPA infusions was 30 h (range: 2-120 h) and 18 h (2-120 h), respectively (p=0.044). Non-fatal major and minor bleeding rates were 12.5% and 16.7% for LD and 3.2% and 25.8% for HD rtPA, respectively. At the end of the rtPA infusions, CCR and PCR were achieved in 32.7% and 49.0% of the episodes, respectively. The most successful site for thrombolysis was intracardiac thrombosis. HD versus LD rtPA administration was not correlated with CCR/PCR or bleeding (p>0.05). Conclusion: Systemic thrombolytic therapy may save lives and organs effectively if it is used at the right indications and the right times in children with high-risk thrombosis by experienced hematologists with close monitoring of recanalization and bleeding