Page 185 - Essential Haematology

Chapter 12 Haematological malignancy: management / 171

valaciclovir is frequently given prophylactically.
Herpes simplex is a common cause of oral ulcers
but is usually controlled easily by aciclovir. Varicella
zoster frequently reactivates in patients with lym-
phoproliferative diseases to cause shingles which
requires treatment with high doses of aciclovir or
valaciclovir. Primary infection, usually in children,
can be very serious and immunoglobulin can be
used to prevent infection following recent exposure.
Reactivation of CMV infection is particularly

important following SCT (see Chapter 23 ) but may
occur following intensive chemotherapy. Failure of
immune control of EBV following allogeneic trans-
plantation can lead to outgrowth of a B - cell tumour
known as post - transplant lymphoproliferative
disease (see p. 312 ).

Fungal i nfection
Figure 12.3 Sporing heads of Aspergillus fumigatus.

Prophylaxis and t reatment of f ungal (Courtesy of Dr Elizabeth Johnson.)
i nfection
Because of the intensity of current chemotherapy,
fungal infections are a major cause of morbidity and
mortality. The two major subtypes are yeasts such A high index of suspicion for fungal infection

as Candida species and moulds of which Aspergillus should be maintained and treatment is often started
fumigatus is the most common. empirically for a fever that has failed to resolve after
Invasive aspergillosis is a common cause of 3 – 4 days of antibiotic treatment.
infectious death in intensively immunocompro- Prophylaxis for patients at risk of Aspergillus
mised patients. Infection occurs through inhalation infection is usually performed with fl uconazole,
of Aspergillus spores (conidia) (Fig. 12.3 ) and air itraconazole, posaconazole or lipid formulation

filtration systems are used in many haematology amphotericin.
wards. The major risk factor is neutropenia – Treatment of established Aspergillus infection is

nearly 70% of patients become infected if they are with voriconazole, lipid formulation amphotericin,
neutropenic for over 34 days. Steroid use is also posaconazole or caspofungin. Surgery to remove
important, as is age, chemotherapy and antimicro- lung lesions may be needed.
bial history. Candida species are a common hospital patho-
The diagnosis of invasive aspergillosis can be gen and frequently cause oral infection. Candida

diffi cult. Definitive diagnosis requires demonstra- can be significant when isolated from normally

tion of invasive growth on a biopsy specimen but sterile body fluids such as blood or urine. Prophylaxis

such evidence is rarely available. Polymerase chain or treatment is usually with fl uconazole, itracona-
reaction for fungal DNA or enzyme - linked immu- zole or caspofungin. Anidulafungin and micafungin
nosorbent assay (ELISA) for Aspergillus galactoman- are also licensed. Pneumocystis jirovecii (carinii) is an
nan or β 1 – 3 d - glucan are useful. High resolution important cause of pneumonitis. Prophylaxis with
computed tomography (HRCT) chest scan is valu- co - trimoxazole or nebulized pentamidine is highly
able and early features are nodular lesions with a effective and is given to those who have received

‘ ground glass ’ halo appearance. Later on, wedge intensive (combination) chemotherapy or fl udarab-
lesions and the air crescent sign are seen (Fig. 12.4 ). ine. Treatment is with high dose co - trimoxazole.