Zygomycosis in a child with severe aplastic anemia who has invasive pulmonary aspergillosis: Hypersensitivity reaction to liposomal amphotericin B and successful challenge [Invaziv pulmoner aspergillozis enfeksiyonu si{dotless}rasi{dotless}nda zigomikoz gelişen agi{dotless}r aplastik anemili olguda lipozomal amfoterisin B allerjisi ve desensitizasyon]

Invasive pulmonary aspergillosis and zygomycosis are fungal opportunistic diseases with a high morbidity and mortality rate, predominantly affecting immunosuppressed patients. In patients with severe aplastic anemia (SAA) more than one invasive mycotic infection should be considered and early diagnosis with adequate treatment is crucial. We present a patient with treatment resistant SAA who developed zygomycosis while under caspofungin + voriconazole combined antifungal therapy for invasive pulmonary aspergillosis. A 13.5 year old boy with SAA developed invasive pulmonary aspergillosis. Liposomal amphotericin B (L-AmB) was started, but he developed an anaphylactic type hypersensitivity reaction with L-AmB. Therefore treatment was changed to voriconazole treatment, and at the 3rd month of this treatment, caspofungin was added as a salvage therapy. However, he did no respond to immunosuppressive treatment for SAA. No clinical or laboratory improvement of invasive fungal infection was seen in spite of antifungal therapy. Clinical nasal/ paranasal zygomycosis occurred and showed a very rapid spread to most parts of the face under this intensive antifungal therapy. Although no destruction of the bones was seen on tomography at first, a fungal infection was suspected and histopathologic/ micologic cultures proved the diagnosis. L-AmB was given with a protocol allowing desensitization since the patient had a history of anaphylactic reaction. This case report is presented in order to illustrate the possibility of more than one fungal infection in an immuncompromised patient in spite of antifungal therapy and documenty a successful L-AmB challenge and possible desensitization in a patient with SAA who had a prior anaphylactic reaction associated with L-AmB