Recurrent Acremonium infection in a kidney transplant patient treated with voriconazole: a case report

Tuon, Felipe Francisco; Pozzi, Carolina; Penteado-Filho, Sergio Ricardo; Benvenutti, Ricardo; Contieri, Fabiana Loss de Carvalho

doi:10.1590/s0037-86822010000400028

Cited by 12 publications

(17 citation statements)

References 8 publications

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“…Although amphotericin B has been used with favorable outcomes in some early reports, voriconazole or posaconazole may be better alternatives, particularly in patients with renal insufficiency. Presently, the clinical experience with the latter drugs in the treatment of Acremonium infections is limited (23,36).…”

Section: Case Reportmentioning

confidence: 99%

Acremonium kiliense: Reappraisal of Its Clinical Significance

et al. 2011

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A case of Acremonium kiliense peritonitis is described. Diagnosis was established by repeated isolation of the fungus from peritoneal dialysate and by its identification on the basis of morphological characteristics and sequencing of internal transcribed spacer (ITS) regions of ribosomal DNA (rDNA). This report and available literature suggest that A. kiliense may have a greater clinical significance than hitherto recognized. CASE REPORTA 75-year-old Jordanian man with a long history of diabetes mellitus and hypertension developed end-stage kidney disease requiring continuous ambulatory peritoneal dialysis (CAPD). His course of CAPD was largely uneventful except for a single episode of bacterial peritonitis, for which he was hospitalized and treated with parenteral antibiotics, with an excellent response. In January 2010, he became febrile, with clinical evidence of peritonitis, and was admitted to the hospital. The peritoneal fluid was turbid, with a white blood cell (WBC) count of 2.1 ϫ 10 9 /liter. On initial microscopic examination, the presence of fungal elements in the peritoneal dialysate was missed. The peritoneal fluid sample was inoculated into aerobic Bactec blood culture bottles, which yielded a growth after 59 h of incubation. The Gram-stained smear from blood culture bottles showed branched hyphal elements. On Sabouraud dextrose agar (SDA; Oxoid Ltd., Basingstoke, England), the specimen yielded slimy colonies with a pinkish appearance ( Fig. 1). Microscopic examination of the primary culture (isolate Kw441-2010) showed hyaline hyphae, with scanty sporulation. A provisional identification of Acremonium/Fusarium species was made, and the growth was subcultured on Sabouraud dextrose agar and oatmeal agar (OMA; oatmeal [30 g], agar [20 g], distilled water [1 liter]) for further identification and antifungal susceptibility testing. Subsequent cultures of the peritoneal fluid yielded the same fungus on three occasions. A serum sample was obtained for the detection of galactomannan (Platelia Aspergillus enzyme immunoassay [EIA] kit; BioRad, Marnes-la-Coquette, France) and (1-3)-␤-D-glucan (Fungitell; Associates of Cape Cod); the latter test was positive (253 pg/ml). An Etest performed on RPMI 1640 medium supplemented with 2% glucose revealed that the isolate was resistant to amphotericin B and caspofungin but susceptible to voriconazole and posaconazole, with MIC values of Ͼ32 g/ml, Ͼ32 g/ml, 0.064 g/ml, and 0.75 g/ml, respectively. The patient was started on voriconazole, with a loading dose of 400 mg, followed by a maintenance dose of 200 mg, given every 12 h via the oral route. Although the patient showed clinical improvement after 2 weeks of voriconazole therapy, the peritoneal dialysate remained turbid (WBC counts, 2.0 ϫ 10 9 / liter). Abdominal ultrasound examination did not reveal any evidence of intraperitoneal adhesions or organ invasion. Since the response to treatment was not adequate, the Tenckhoff catheter was removed and the patient was temporarily switched to hemodialysis. After 1 week of a...

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Section: Case Reportmentioning

confidence: 99%

Acremonium kiliense: Reappraisal of Its Clinical Significance

et al. 2011

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“…Surgical debridement with concomitant antifungal therapy constitute standard treatment, but isolates vary in their susceptibility to amphotericin B and azoles (6). To our knowledge, this is the first instance of a renal allograft recipient who responded to surgical drainage and immunosuppression reduction alone, as previous reports described clearance with a combination of surgical drainage and ketoconazole (7), voriconazole (8), and posaconazole (9), respectively.…”

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confidence: 74%

Resolution of Acremonium kiliense subcutaneous abscess in a renal allograft recipient without antifungal therapy

Valson

Kakde

Mohanraj

et al. 2014

Transplant Infectious Dis

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“…Although this drug was able to reduce fungal load in some organs in our study, it was ineffective in prolonging survival for any of the strains tested, which suggests that this drug should be used with caution in cases of human infection. Clinical experience with VRC is more limited; however, some cases of successful treatment with that drug have been reported, although the drug MICs for the Acremonium strains were high (21,23,37,38). Unfortunately, in almost all the cases the Acremonium isolates were not identified at the species level (38).…”

Section: Discussionmentioning

confidence: 99%

Evaluation of the Efficacies of Amphotericin B, Posaconazole, Voriconazole, and Anidulafungin in a Murine Disseminated Infection by the Emerging Opportunistic Fungus Sarocladium (Acremonium) kiliense

Fernández-Silva

Capilla²,

Mayayo³

et al. 2013

Antimicrob Agents Chemother

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We evaluated and compared the efficacies of different antifungal drugs against Sarocladium kiliense (formerly Acremonium kiliense), a clinically relevant opportunistic fungus, in a murine model of systemic infection. Three clinical strains of this fungus were tested, and the therapy administered was as follows: posaconazole at 20 mg/kg of body weight (twice daily), voriconazole at 40 mg/kg, anidulafungin at 10 mg/kg, or amphotericin B at 0.8 mg/kg. The efficacy was evaluated by prolonged animal survival, tissue burden reduction, and (1¡3)-␤-D-glucan serum levels. In general, the four antifungal drugs showed high MICs and poor in vitro activity. The efficacy of the different treatments was only modest, since survival rates were never higher than 40% and no drug was able to reduce fungal load in all the organs for the three strains tested. Posaconazole, in spite of its high MICs (>16 g/ ml), showed the highest efficacy. The (1¡3)-␤-D-glucan serum levels were equally reduced by all drugs evaluated.A cremonium kiliense is a saprobic fungus with a worldwide distribution which has been reported in recent years as an emerging opportunistic pathogen able to cause a wide range of human infections (1-4). Localized infections, such as mycetoma, keratitis, or onychomycosis, are acquired mainly by immunocompetent patients through trauma (5-11). Invasive infections generally affect immunosuppressed hosts such as those undergoing transplantation or those with AIDS, resulting in a high degree of fatality (12-16). More rarely, though, invasive infections have also been reported in immunocompetent individuals (17,18). Recently, based on molecular studies, this fungus has been transferred to the genus Sarocladium as Sarocladium kiliense (1). This species is the most clinically relevant of the genus and apparently also the most virulent (4,19,20). Considering that the morphological identification of these fungi is difficult, it is likely that some clinical isolates of this species have been misidentified as Acremonium strictum, another clinically important species of Acremonium (19). Infections by Acremonium spp. are difficult to treat due to the intrinsic resistance to the current antifungal agents, and an effective treatment has not yet been determined (19,(21)(22)(23). Amphotericin B (AMB) is the drug most commonly used to treat severe fungal infections caused by opportunistic molds (4). Despite its poor in vitro activity and variable clinical results, this drug still remains the first therapeutic choice against invasive Acremonium infections (2, 4, 19). Clinical experience with other drugs, such as posaconazole (PSC), voriconazole (VRC), and the echinocandins, is very poor.To evaluate possible therapeutic strategies, we tested the efficacies of PSC, VRC, and anidulafungin (AFG) compared to that of AMB against S. kiliense in a recently developed murine model of disseminated infection (20). MATERIALS AND METHODSThree clinical strains of Sarocladium kiliense, UTHSC 01-2238, UTHSC 03-3197, and UTHSC 07-550, previously identified by...

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Recurrent Acremonium infection in a kidney transplant patient treated with voriconazole: a case report

Cited by 12 publications

References 8 publications

Acremonium kiliense: Reappraisal of Its Clinical Significance

Acremonium kiliense: Reappraisal of Its Clinical Significance

Resolution of Acremonium kiliense subcutaneous abscess in a renal allograft recipient without antifungal therapy

Evaluation of the Efficacies of Amphotericin B, Posaconazole, Voriconazole, and Anidulafungin in a Murine Disseminated Infection by the Emerging Opportunistic Fungus Sarocladium (Acremonium) kiliense

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