Purpose: Aspergillus osteomylitis has been reported as a result of dissemination in solid organ transplant recipients. Vertebral osteomylitis is one of the most common forms of Aspergillus osteomyelitis. However, an Aspergillus fungus ball is a rare cause of ureteral obstruction. Methods: We describe an unusual case of simultaneous vertebral osteomyelitis and ureteral obstruction caused by A. flavus in a hepatic transplant recipient, who was successfully treated with sequential intravenous and oral itraconazole solution. Results: A 46-year-old man with hepatitis B-related cirrhosis and end-stage hepatic failure underwent liver transplant in August 2007. Two weeks later, he developed cough, dyspnea and fever. The chest radiograph showed bilateral infiltration, and A. flavus was isolated from the sputum. He was initially treated with micafungin IV (100mg/d) for 2 weeks. His symptoms improved but there were persistent low-grade fevers. Amphotericin B colloidal dispersion (ABCD) (100mg/d) replaced micafungin for 10 days, but fever persisted. Oral voriconazole (400mg/d) was then used in place of ABCD, and the patient became afebrile. After the resolution of symptoms, the patient was discharged and continued oral voriconazole (400mg/d) therapy, for 2 weeks total. However, he was readmitted for low back pain of two months’ duration. A roentgenogram showed narrowing, partial collapse, and lytic lesions in the L4-5 vertebrae. The patient underwent excision of the necrotic vertebral tissue and spinal stabilization with screw fixation. Culture of tissue specimens was positive for A. flavus. After surgery, intravenous voriconazole was started for 3 weeks and then switched to oral therapy. Ten weeks later, the lumbar pain became unbearable, with neither fever nor other symptoms. A magnetic resonance imaging (MRI) revealed erosion of L1-5 vertebrae and intervertebral discs. Whole-body positron emission tomography/computed tomography (PET/CT) scan using F18-fluorodeoxyglucose (PDG) revealed hypermetabolic foci highly suggestive of an infectious process in the same region. An ultrasound showed moderate right hydroureteronephrosis. ABCD was prescribed, but discontinued in 4 days due to an elevated creatinine (1.65mg/dL) and abnormal liver function tests. After that, therapy with intravenous itraconazole was instituted at 200mg per day. One week later, the patient achieved complete remission of hydroureteronephrosis. Microscopic examination of the mass revealed dichotomously branched septated hyphae, consistent with Aspergillus species. One month later, his severe low back pain was markedly diminished. Two months later, MRI of the lumbar vertebrae showed improvement. Itraconazole was then administered as alternate cycles of 1-week intravenous formulation (200mg/d) and 2-week oral solution (400mg/d), for a total of 5 months. The patient then received itraconazole oral solution (400mg/d) for another 12 weeks. Follow-up FDG-PET/CT scan of the spine showed a normalization of FDG uptake, which correlated well with clinical improvement. Oral itraconazole was continued for 3 months at a dosage of 200mg daily. After a total of 15 months, itraconazole was discontinued. The patient remained well 4 months after withdrawal of itraconazole. Conclusions : Aspergillus vertebral osteomyelitis should be considered in transplanted patients with back pain and imaging evidence of vertebral destruction. Our results suggest itraconazole is a drug of choice for Aspergillus osteomyelitis and ureteral obstruction, even in patients who fail to respond to voriconazole therapy. FDG-PET/CT may be a helpful tool for evaluation of treatment response in Aspergillus vertebral osteomyelitis.
Full conference title:
4th Advances Against Aspergillosis
- AAA 4th (2010)