Gregoria Bertuna

Spleen and lung involvement by Acinetobacter calcoaceticus bacteremia mimicking deep fungal infection in a child with acute non-lymphoblastic leukemia.

To the Editor: A 10-year-old boy was diagnosed for acute myeloid leukemia. A Groshong central venous catheter (CVC) was inserted, and after the first cycle of chemotherapy, he became febrile and received empirical ceftriaxone and amikacin followed by defervescence. Four days later, while he was neutropenic, fever reappearedandAcinetobactercalcoaceticuswasisolatedfrom both catheter and peripheral vein blood cultures as well as from upper airways secretion. Ciprofloxacin was added, but the child remained febrile and showed respiratory distress. Body CT scan did not show any pulmonary abnormalities, but was marked by the presence of some nodules in the spleen. We considered these findings consistent with possible splenic candidosis despite negative antigenemia and cultures for Candida, and the persistent isolation of Acinetobacter from cultures. We, therefore, added caspofungin to his therapy. We decided not to remove the CVC due to the poor peripheral venous accesses. Fever persisted for 21 days along with positive cultures for Acinetobacter. Aspergillus galactomannan antigen test was negative. We documented complete remission from leukemia and administered the second cycle of chemotherapy, together with ciprofloxacin and caspofungin. The patient remained apyretic, and blood cultures became negative. After haematological recovery, CT scan revealed no spleen nodules, but many round lesions in both lungs, a few with central cavitation. We concluded that the spleen and lung lesions were likely due to Acinetobacter infection. Consequently, other cycles of chemotherapy, including autologous haematopoietic stem cell transplantation, were administered together with ciprofloxacinasa singleagent. Oneyear aftertransplantation, the child remains in remission. Lung and spleen CT nodules in a persistently febrile neutropenic patient were considered of fungal origin in spite of positive bacterial blood cultures. However, in retrospect, a critical review of CT imaging suggested a different possibility. The splenic lesions were present during neutropenia, while hepatosplenic candidiasis usually became evident at the CT scan with recovery of neutrophils. The chest CT findings were also consistent with Acinetobacter infection. CVCremoval could have changed the clinical course of our patient, but we decided to keep it because of the poor peripheral accesses and the need for a stable way to administer supportive care. This case suggests that bacteraemia should be considered as a cause for such CT findings in this clinical scenario.