Zygomycosis in children: disseminated infection caused by Cunninghamella bertholletiae.

Infections by Cunninghamella bertholletiae are infrequent but particularly severe and have high associated mortality. Gomes et al.1 reported 6 pediatric cases, 4 with pneumonia and 2 with disseminated disease. In said study, hematologic disease was the majority risk factor. Three patients with lung affectation who underwent surgery and antifungal treatment survived. Our case is a 17-year-old patient who was diagnosed in 2006 with acute lymphoblastic leukemia-B and admitted for unrelated allogeneic transplantation in 2011 and had received prophylaxis with amphotericin B (AMB) liposomal, acyclovir and trimethoprim/sulfamethoxazole. Antibiotic prophylaxis (+6) was started with meropenem due to neutropenia with no fever. Vancomycin (+10) was associated after daily fever and increased acute-phase reactants coinciding with the leukocyte transplantation. On day +41, the patient was hospitalized due to persistent diarrhea with no microbiological confirmation that was treated with meropenem and ganciclovir. The pathology study of the colon suggested grade I graft-versus-host disease (GVHD), which evolved to grade III in a later study. On day +64, the subject presented a single painful erythematous lesion in the left hypochondriac region suggestive of septic embolism. The biopsy report identified angioinvasive mycosis suggestive of mucormycosis. On thoracoabdominal-pelvic CT, a nodular lesion was observed in the left lung compatible with a fungal infection. Pathology studies were done of the skin, bone marrow and lungs. The skin and lung studies revealed angioinvasive mycosis compatible with zygomycosis. From the culture of the lung nodule, Cunninghamella spp. was isolated and with pan-fungal CRP (ISCIII) it was identified as C. bertholletiae. Blood cultures were negative. Liposomal AMB was administered at high doses (10 mg/kg/day) along with terbinafine (TER) and posaconazole (PSC). The MIC of these antifungal preparations was 4, 8, and 2 g/ml, respectively. The lung nodule and skin lesion were resected (+72). During post-op in the pediatric ICU, vancomycin and amikacin were added to meropenem due to an increase in acute-phase reactants with negative blood cultures. A series of radiological controls detected a left lung infiltrate with pleural effusion. Given the respiratory deterioration, a new pulmonary CT showed an increase in the effusion and nodular lesions in the