Purpose: Posaconazole (POS) is a new, broad-spectrum triazole antifungal with excellent in vitro activity against Exophiala spp (eg, Exophiala spinifera and Exophiala jeanselmei), suggesting that it is a rational choice for the treatment of infections caused by these dematiaceous fungi. This case report describes the successful use of POS to treat a life-threatening, disseminated E. spinifera infection following failure of standard therapies. Clinical Problem: A 41-year-old woman with no evidence of immunodeficiency experienced a 9 year long relapsing course of disseminated phaeohyphomycosis due to E. spinifera. Despite treatment with numerous antifungals, including repeated cycles of itraconazole plus flucytosine, IV amphotericin B (AMB), griseofulvin, fluconazole, and terbinafine, only partial and transient improvement of the fungal lesions was seen, and the duration of remissions became progressively shorter as the disease persisted. When the patient became pregnant (9 years after initial presentation), the mycosis increased in severity until it became life-threatening, necessitating premature delivery by cesarean section and aggressive treatment of the infection with IV AMB. At that time, the patient was febrile with vegetating, verrucous lesions on the upper limbs and back, lymphadenopathy, and small papules on the forehead and thighs. The lesions secreted a purulent, foul-smelling discharge. The left knee was painful, swollen, and had limited mobility. Visual acuity was diminished, with exudative foci and hemorrhage in the left eye. Cultures of the lymph nodes and bone biopsy of the knee revealed E. spinifera. Clinical Approach: Because other antifungal agents had been minimally effective, treatment was initiated with POS suspension 200mg orally qid after meals. Intravenous ceftriaxone 2g/day and oral ciprofloxacin 1 g/day were also begun to treat a secondary bacterial infection. Patient Outcome: After 7 days of treatment, the patient was afebrile and markedly improved. After 1 month, the patient was discharged from the hospital, and she continued to receive POS 400 mg bid as an outpatient. After two months of treatment, the patient had significant clinical response of her skin lesions. With continued treatment, complete clinical and mycologic cures were achieved within 13 months of initiating POS, and completed therapy as planned. The patient experienced a recurrence of E. spinifera infection within the following year, which was treated with a second course of POS 400 mg bid. Since restarting POS, clinical and mycologic responses have been excellent, with no signs of active lesions. In addition, long term suppressive therapy with POS has been well tolerated. Conclusions: In this patient, POS suspension was effective and well tolerated for the treatment of a life-threatening episode of disseminated phaeohyphomycosis due to E. spinifera. In addition, maintenance therapy with POS has been effective as prophylaxis against future episodes.
Full conference title:
The 15 th Congress of the International Society for Human and Animal Mycology
- ISHAM 15th (2003)