1130531--高雄地区第499次小儿科联合病例讨论会-高雄市医师公会.辫诲蹿
- 1. 2024/04/18 1 May 31st, 2024 聖功醫院小兒科 羅文聰醫師 台灣兒科醫學會 高雄地區兒科聯合病例討論會 病例報告 Chief complaint ? For regular chemotherapy with 6 courses of CIE regimen. Present illness 2 years ago A palpable abdominal mass was found accidently. Radical nephrectomy, left and Port-A catheter implantation Wilm’s tumor was confirmed by pathology. Chemotherapy with TPOG W97-2 protocol for 27 weeks 10 months later 6 months later 11 months later Multiple metastasis including lung, liver and spine was found. → Stage 4R Chemotherapy with NWTS-5 relapse protocol for 7 courses Shifted chemotherapy to TPOGW97-4b regimen 15 weeks due to poor response to NWTS-5 relapse protocol. Currently Shifted chemotherapy to CIE regimen. Past and personal history Operation history: 1. Exp. Lap. with radical nephrectomy, left and lymph nodes dissection (2 years ago). 2. Port-A catheter implantation via left jugular vein.
- 2. 2024/04/18 2 Physical examination ? General condition: failure to thrive. ? HEENT: no pale conjunctiva, no icteric sclera, no stiffness, no cervical lymphadenopathy, no oral ulcer, no hair. ? Chest: Port-A implant over left chest. ? Abdomen: no hepatomegaly or splenomegaly, hyperactive bowel sounds, tympanic percussion sounds, no rebounding pain, surgical scar about 18cm over the abdomen. ? Extremities: no deformity of the spine or limbs, no joint stiffness, tenderness over L-spine region. ? Neurologic: paresthesia over right inguinal region and bilateral lower limbs, weakness of bilateral lower limbs (muscle power 2-3), absent deep tendon reflex over bilateral lower limbs. Diagnosis ? Wilm’s tumor, post radical nephrectomy, left and 27th week regular chemotherapy with TPOG W97-2, recurrence with lung, liver and spine metastasis, stage 4R, post 7th week regular chemotherapy with TPOGW97-4a relapse protocol, 18th week regular chemotherapy with TPOGW97-4b relapse protocol, and 5th ICE course protocol. Hospital course Day 2 Day 1 Day 3 Chemotherapy with Carboplatin + Isofamide + Etoposide Abdominal pain and fever developed. Stopped chemotherapy. Administration ampicillin + gentamicin Checked B/C, U/C Day 12 Day 9 Day 14 Fever subsided after ampicillin and gentamicin administration for 2 days, then ceased antibiotics usage after no bacteria growth for 7 days. Fever recurred while ANC=0. Collected B/C, U/C, and consulted INF for meropenem (60mg/kg/day). Fever subsided. U/C: E. coli, K. pneumoniae were both susceptible to meropenem Day 18 Day 17 Day 19 Fever recurred under meropenem. Collected B/C from Port-A, and CRP was 7.37mg/dl. Added vancomycin (60mg/kg/day ). Added fluconazole (6mg/kg/day). Fever persisted, CRP was 17.9 mg/dl. Yeast was detected from B/C. Collected B/C from peripheral vein. Day 23 Day 21 Day 24 Fever persisted. Adjusted dosage of fluconazole from 6 to 9mg/kg/day, then was shifted to amphotericin B. Removed Port-A, and collected B/C from femoral vein. Yeast was detected from B/C. Yeast was detected from B/C. Previous yeast was Kodamaea ohmeri which was susceptible to fluconazole.
- 3. 2024/04/18 3 Day 24-37 Because Kodamaea ohmeri was susceptible to fluconazole, we shifted anti-fungal agent to fluconazole alone. After removal of Port-A, the patient’s WBC count increased and fever subsided. We kept fluconazole treatment for two weeks, and no fungus was detected from his blood. Final Diagnosis ? Wilm’s tumor, post radical nephrectomy, left and 27th week regular chemotherapy with TPOG W97-2, recurrence with lung, liver and spine metastasis, stage 4R, post 7th week regular chemotherapy with TPOGW97-4a relapse protocol, 18th week regular chemotherapy with TPOGW97-4b relapse protocol, and 5th ICE course protocol. ? Fungemia caused by Kodamaea ohmeri. Review ? Kodamaea ohmeri (Pichia ohmeri or Yamadazyma ohmeri), is a yeast within the family of Saccharomycetaceae. ? K. ohmeri is the teleomorphic form of Candida guilliermondii and is widely used for the fermentation of fruit, pickles, and rinds. ? The first clinical isolate was from pleural effusion and was considered a contaminant. Kodamaea ohmeri ? The symptoms of K. ohmeri infection varied, and included fever, acute pain, and malaise. ? All the patients known were immunocompromised. ? K. ohmeri infection in immunocompromised patients should be considered a potentially critical condition. Symptom ? The current treatment strategy for K. ohmeri infections includes the removal of medical devices (e.g., Foley catheter, central venous catheter, and pacemaker) and the use of effective antifungal agents. ? Previous reports have suggested that amphotericin B and fluconazole are effective in the treatment of K. ohmeri fungemia. Treatment
- 4. 2024/04/18 4 2005 July ? Most cases of K. ohmeri infections were reported to be responsive to removal of catheter and treatment with three antifungal agents (amphotericin B, fluconazole, and itraconazole). ? There was no clear indication of which drug was preferable to the others. Treatment ? The evidence indicates that K. ohmeri should be added to the list of potential yeast pathogens that can cause systemic infections in humans of all ages, particularly in immunocompromised patients. ? Because increasing numbers of cases of K. ohmeri fungemia have been reported with high mortality, early diagnosis and appropriate treatment with removal of any implanted devices are vital in the management of this potentially fatal infection. Conclusion Thank you for your attention