Anstead G 1,2 , Martinez M 1,2 , Graybill J 1

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Purpose: Posaconazole (POS) is a new broad-spectrum triazole antifungal with excellent activity against Candida spp, Aspergillus spp, and Zygomycetes spp. This case describes the use of POS to control an endovascular transjugular intrahepatic portosystemic shunt (TIPS) infection due to Candida glabrata in a severely immunocompromised patient. Clinical Problem: A 63-year-old Hispanic man with a history of end-stage liver disease, esophageal varices, and recurrent gastrointestinal bleeding was admitted to the hospital for a TIPS procedure; soon after, he was diagnosed with a Klebsiella pneumoniae infection, for which he received levofloxacin. Twelve days after finishing levofloxacin therapy, the patient was admitted to the hospital for bacteremia (methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus faecium, and K. pneumoniae) and candidemia due to Candida glabrata (fluconazole [FLU] MIC = 2 mg/mL). The patient was treated with FLU 400 mg/d IV and PO for a total of 72 days. Blood cultures were negative 6 days after initiation of FLU. Seven months after this hospital stay, the patient became febrile and was noted to be neutropenic (absolute neutrophil count = 100 cells/mL). Blood cultures grew C. glabrata; amphotericin B (AMB) therapy was initiated. CT scan of the abdomen showed a partially occlusive thrombus extending from the TIPS stent into the suprahepatic inferior vena cava (IVC) and ending near the right atrium. The clinical impression was probable C. glabrata endovascular infection. Despite AMB therapy, repeated blood cultures were positive for C. glabrata. MIC values of the C. glabrata isolate were 16, 1, and 0.5 mg/mL for FLU, itraconazole, and POS, respectively. Clinical Approach: Based on susceptibility testing results and clinical evidence of fungemia refractory to standard FLU and AMB therapy, treatment with POS suspension (200 mg PO qid) was initiated. Patient Outcome: For the next 6 weeks, blood cultures were negative for C. glabrata. CT scan of the abdomen on Day 59 of POS therapy showed resolution of the IVC thrombus but evidence of a hepatic mass. Hepatocellular carcinoma was diagnosed. Liver function worsened secondary to the hepatocellular carcinoma, and hepatic encephalopathy developed. The patient became noncompliant with POS therapy, and subsequent blood cultures grew C. glabrata. The patient died from hepatocellular carcinoma and hepatic encephalopathy 3 months after beginning POS therapy. Conclusions: This case illustrates the efficacy of POS in the control of a prosthetic endovascular infection with a fluconazole-resistant strain of C. glabrata in an immunocompromised patient with end-stage liver disease who had failed AMB. While intercurrent events make it difficult to assess overall clinical response, palliation of the patient’s condition with clearance of fungemia was achieved with POS therapy when removal of the TIPS and more aggressive intervention was clinically contraindicated.

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The 15 th Congress of the International Society for Human and Animal Mycology
    • ISHAM 15th (2003)