Resistant Fusarium solani Endocarditis in a 3-Month-Old Patient Treated with Liposomal Amphotericin and Voriconazole

JUDITH A. GUZMAN-COTTRILL, DO, ELLEN G. CHADWICK, MD and XIAOTIAN ZHENG, MD, PhD,

Author address: 

Children’s Memorial Hosp., Chicago, IL

Abstract: 

Introduction: Fusarium is a ubiquitous, opportunistic fungus causing invasive disease in immunocompromised hosts. Treatment is a challenge, as Fusarium spp are highly resistant to antifungal agents. We report a child who has survived Fusarium solani endocarditis, despite the organism’s in vitro panresistance. Case: A 2-month-old girl with congenital AML was admitted for chemotherapy. On hospital day (HD) #5, she was febrile but well-appearing. Her absolute neutrophil count (ANC) was 28. Broad spectrum antibiotics were intiated; fevers persisted and liposomal amphotericin (3mg/kg/d) was added on HD #10. A diffuse, tender, erythematous nodular rash was noted on HD #15; skin biopsy and multiple blood cultures (BCs) grew F. solani. An echocardiogram was negative for vegetations. Indwelling lines were removed, the amphotericin dose was increased to 10 mg/kg/d, and voriconazole added; subsequent BCs were negative. The Fusarium was resistant to all antifungals tested (fluconazole 64 ug/ml, 5-FC 64 ug/ml, amphotericin 8 ug/ml, caspofungin 16 ug/ml, voriconazole 8ug/ml). Despite in vitro data, amphotericin and voriconazole were continued. Chemotherapy was held, a granulocyte transfusion was given, and her ANC recovered. On HD #36, new skin lesions were noted; skin cultures again grew F. solani but BCs remained negative. An echocardiogram revealed two 2x6mm mitral valve vegetations. The patient remained stable without surgical intervention, and the vegetation size was stable on serial echocardiograms. To date, she has received 3 months of therapy and is stable. Chemotherapy remains on hold. Discussion: Fusarium endocarditis is a rare disease. Upon review of the literature, we found 5 previously reported cases; all 5 patients expired despite antifungal therapy. Our patient is the only known report of Fusarium endocarditis treated with voriconazole and amphotericin; although the in vitro data showed resistance to all antifungals, our patient’s disease is under control with combination therapy. As invasive Fusarium spp infections continue to increase, more approaches to treatment of this highly resistant organism are needed.
2003

abstract No: 

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Full conference title: 

41st Annual Meeting Infectious Diseases Society of America
    • Infectious Diseases Society of America 41st