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Invasive Microascus trigonosporus Species Complex Pulmonary Infection in a Lung Transplant Recipient.

Schoeppler KE, Zamora MR, Northcutt NM, Barber GR, O'Malley-Schroeder G, Lyu DM - Case Rep Transplant (2015)

Bottom Line: Because of the high incidence of morbidity and mortality associated with invasive fungal infections, antifungal prophylaxis is often used in solid organ transplant recipients.Nebulized liposomal amphotericin B was used in addition to systemic therapy in order to optimize antifungal drug exposure; this regimen appeared to reduce the patient's fungal burden.Despite this apparent improvement, the patient's pulmonary status progressively declined in the setting of multiple comorbidities, ultimately leading to respiratory failure and death.

View Article: PubMed Central - PubMed

Affiliation: Department of Pharmacy, University of Colorado Hospital, Aurora, CO 80010, USA.

ABSTRACT
Because of the high incidence of morbidity and mortality associated with invasive fungal infections, antifungal prophylaxis is often used in solid organ transplant recipients. However, this prophylaxis is not universally effective and may contribute to the selection of emerging, resistant pathogens. Here we present a rare case of invasive infection caused by Microascus trigonosporus species complex in a human, which developed during voriconazole prophylaxis in a lung transplant recipient. Nebulized liposomal amphotericin B was used in addition to systemic therapy in order to optimize antifungal drug exposure; this regimen appeared to reduce the patient's fungal burden. Despite this apparent improvement, the patient's pulmonary status progressively declined in the setting of multiple comorbidities, ultimately leading to respiratory failure and death.

No MeSH data available.


Related in: MedlinePlus

Microscopy. Lactophenol cotton blue stain. Note many overlapping conidiophores and conidia of Scopulariopsis sp. grown from patient's BAL sample fluid (10x).
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fig2: Microscopy. Lactophenol cotton blue stain. Note many overlapping conidiophores and conidia of Scopulariopsis sp. grown from patient's BAL sample fluid (10x).

Mentions: Three months after discharge, he presented to our facility in follow-up after moving to our region. His immunosuppression consisted of tacrolimus (trough = 6.4 ng/mL), mycophenolate mofetil 250 mg twice daily, prednisone 10 mg daily, and inhaled fluticasone/salmeterol 250/50 mcg twice daily. He had been receiving voriconazole 200 mg twice daily for fungal prophylaxis since day 1 postoperatively in addition to sulfamethoxazole-trimethoprim and valganciclovir. At presentation he was noted to have worsening dyspnea, dry cough, increasing malaise, and low-grade fevers. Physical exam findings were consistent with distal airway narrowing by auscultation. FEV1 was 0.92 L/s (29% predicted). Chest radiography (CXR) showed diffuse patchy infiltrates and small bilateral pleural effusions (Figure 1). Bronchoscopy revealed multiple endobronchial strictures but no endobronchial plaques, and intravenous (IV) high-dose steroids (methylprednisolone 10 mg/kg once daily × 3 days) were given for probable acute rejection (AR). Transbronchial biopsies did not demonstrate AR (A0), but the bronchoalveolar lavage (BAL) fluid grew moderate mold 5 days later. Posaconazole 400 mg twice daily was started for empiric treatment of a breakthrough fungal infection, and the patient's esomeprazole was held to facilitate absorption. Speciation of the mold occurred at day 11, revealing moderate Scopulariopsis sp. on culture, with morphology most consistent with S. brumptii by microscopy (Figure 2). Later, DNA sequencing of the internal transcribed spacer (ITS) region would identify the mold as Microascus trigonosporus species complex. Confirmatory DNA sequencing of the organism was attempted at a second laboratory and was unsuccessful.


Invasive Microascus trigonosporus Species Complex Pulmonary Infection in a Lung Transplant Recipient.

Schoeppler KE, Zamora MR, Northcutt NM, Barber GR, O'Malley-Schroeder G, Lyu DM - Case Rep Transplant (2015)

Microscopy. Lactophenol cotton blue stain. Note many overlapping conidiophores and conidia of Scopulariopsis sp. grown from patient's BAL sample fluid (10x).
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4446491&req=5

fig2: Microscopy. Lactophenol cotton blue stain. Note many overlapping conidiophores and conidia of Scopulariopsis sp. grown from patient's BAL sample fluid (10x).
Mentions: Three months after discharge, he presented to our facility in follow-up after moving to our region. His immunosuppression consisted of tacrolimus (trough = 6.4 ng/mL), mycophenolate mofetil 250 mg twice daily, prednisone 10 mg daily, and inhaled fluticasone/salmeterol 250/50 mcg twice daily. He had been receiving voriconazole 200 mg twice daily for fungal prophylaxis since day 1 postoperatively in addition to sulfamethoxazole-trimethoprim and valganciclovir. At presentation he was noted to have worsening dyspnea, dry cough, increasing malaise, and low-grade fevers. Physical exam findings were consistent with distal airway narrowing by auscultation. FEV1 was 0.92 L/s (29% predicted). Chest radiography (CXR) showed diffuse patchy infiltrates and small bilateral pleural effusions (Figure 1). Bronchoscopy revealed multiple endobronchial strictures but no endobronchial plaques, and intravenous (IV) high-dose steroids (methylprednisolone 10 mg/kg once daily × 3 days) were given for probable acute rejection (AR). Transbronchial biopsies did not demonstrate AR (A0), but the bronchoalveolar lavage (BAL) fluid grew moderate mold 5 days later. Posaconazole 400 mg twice daily was started for empiric treatment of a breakthrough fungal infection, and the patient's esomeprazole was held to facilitate absorption. Speciation of the mold occurred at day 11, revealing moderate Scopulariopsis sp. on culture, with morphology most consistent with S. brumptii by microscopy (Figure 2). Later, DNA sequencing of the internal transcribed spacer (ITS) region would identify the mold as Microascus trigonosporus species complex. Confirmatory DNA sequencing of the organism was attempted at a second laboratory and was unsuccessful.

Bottom Line: Because of the high incidence of morbidity and mortality associated with invasive fungal infections, antifungal prophylaxis is often used in solid organ transplant recipients.Nebulized liposomal amphotericin B was used in addition to systemic therapy in order to optimize antifungal drug exposure; this regimen appeared to reduce the patient's fungal burden.Despite this apparent improvement, the patient's pulmonary status progressively declined in the setting of multiple comorbidities, ultimately leading to respiratory failure and death.

View Article: PubMed Central - PubMed

Affiliation: Department of Pharmacy, University of Colorado Hospital, Aurora, CO 80010, USA.

ABSTRACT
Because of the high incidence of morbidity and mortality associated with invasive fungal infections, antifungal prophylaxis is often used in solid organ transplant recipients. However, this prophylaxis is not universally effective and may contribute to the selection of emerging, resistant pathogens. Here we present a rare case of invasive infection caused by Microascus trigonosporus species complex in a human, which developed during voriconazole prophylaxis in a lung transplant recipient. Nebulized liposomal amphotericin B was used in addition to systemic therapy in order to optimize antifungal drug exposure; this regimen appeared to reduce the patient's fungal burden. Despite this apparent improvement, the patient's pulmonary status progressively declined in the setting of multiple comorbidities, ultimately leading to respiratory failure and death.

No MeSH data available.


Related in: MedlinePlus