Intracavitary Voriconazole for Symptomatic Pseudallescheria boydii Pulmonary Mycetomas in a Patient with Fibrocystic Sarcoidosis,

J.N. Kravitz, M.D.1, M.A. Judson, MD2

Author address: 

1Charleston/US, 2Charleston, SC/US

Abstract: 

Pseudallescheria boydii can colonize devitalized lung as a mycetoma. Pulmonary mycetoma (PM) formation in fibrocystic (FC) sarcoidosis is common and may cause life-threatening hemoptysis. Although previous reports described intracavitary antifungal therapy in symptomatic PM, the use of intracavitary voriconazole, to our knowledge, is not found in the literature. We report a case of a patient with FC sarcoidosis presenting with P. boydii PMs complicated by hemoptysis successfully treated with intracavitary voriconazole. A 65-year old man with biopsy-proven FC sarcoidosis presented with hemoptysis of ½ cup daily, weight loss, persistent cough, and dyspnea. He had no chest pain, fever, chills, or night sweats. He was chronically immunosuppressed with tacrolimus and prednisone for a cadaveric renal transplant he received 6 ½ years prior for hypertensive renal disease. Two right upper lobe (RUL) PMs were found one year previously on chest CT, at which time P. boydii was grown from bronchoalveolar lavage and sputum cultures. Aspergillus serum preciptins and antigen were negative. Subsequent chest CT revealed biapical PMs. Nine months prior to presentation, he developed mild daily hemoptysis. Oral voriconazole was initiated with temporary cessation of hemoptysis. The drug, however, was discontinued secondary to hallucinations; and hemoptysis returned and worsened prompting presentation. Physical examination revealed normal vital signs and no adventitial breath sounds. Pulmonary function testing showed moderate restriction. Enlargement of the RUL cavities was noted on repeat chest CT. Arteriography demonstrated extravasation from a right bronchial artery which was embolized. An 8 French drainage catheter was percutaneously placed under CT-guidance with the catheter tip positioned in one RUL cavity and sideport in the other. The PM was aspirated and fungal cultures grew P. boydii. A total of 25 mg of voriconazole in 27.5 ml 0.9% NaCl was instilled via the catheter daily for 10 days, after which hemoptysis significantly decreased. Mild cough occurred with instillation; and he experienced no hallucinations during therapy. At one month follow-up, he had only scant hemoptysis. This is the first report describing intracavitary voriconazole in the treatment of symptomatic PM. P. boydii is susceptible to most azoles, including voriconazole, but resistant to amphotericin B. Surgery for PM is almost always precluded in FC sarcoidosis because of poor pulmonary function and non-localized disease. In our experience, intracavitary antifungal therapy using appropriate drug is effective in controlling PM complicated by serious hemoptysis in this patient population. Am J Respir Crit Care Med 181;2010:A2951
2010

abstract No: 

Poster Board # C24

Full conference title: 

American Thoracic Society International Conference
    • ATS 2010