Fatal breakthrough mucormycosis in a multivisceral transplant patient receiving micafungin: Case report and literature review

Abstract

IntroductionAntifungal agents are routinely used in the post-transplant setting for both prophylaxis and treatment of presumed and proven fungal infections. Micafungin is an echinocandin-class antifungal with broad antifungal cover and favorable side effect profile but, notably, it has no activity against molds of the order Mucorales.Presentation of caseA 47-year-old woman underwent multivisceral transplantation for intestinal failure-associated liver disease. She had a prolonged post-operative recovery complicated by invasive candidiasis and developed an intolerance to liposomal amphotericin B. In view of her immunosuppression, she was commenced on micafungin as prophylaxis to prevent invasive fungal infection. However, she developed acute graft versus host disease with bone marrow failure complicated by disseminated mucormycosis which was only diagnosed post mortem.DiscussionNon-Aspergillus breakthrough mold infections with micafungin therapy are rare with only eight other cases having been described in the literature. Breakthrough infections have occurred within one week of starting micafungin. Diagnosis is problematic and requires a high degree of clinical suspicion and microscopic/histological examination of an involved site. The management of these aggressive infections involves extensive debridement and appropriate antifungal cover.ConclusionA high level of suspicion of invasive fungal infection is required at all times in immunosuppressed patients, even those receiving antifungal prophylaxis. Early biopsy is required. Even with early recognition and aggressive treatment of these infections, prognosis is poor.

Fungal endocarditis in transplant recipients: A systematic review

“…Eleven additional studies were found during the hand‐screening of the included articles’ references or the hand‐screening of the references of narrative reviews. Finally, 60 met the present study's inclusion criteria 5,6,11‐68 . The review process is graphically presented in Figure 1.…”

Global Epidemiology of Mucormycosis

“…Similarly, breakthrough mucormycosis has been reported after echinocandin prophylaxis in 10-14% of mucormycosis cases [104,105,106]. A recent study reported six cases of breakthrough mucormycosis after micafungin prophylaxis [107]. A stringent case control study is essential to investigate the association of antifungal agents in breakthrough mucormycosis and clinicians should be aware of the risk of mucormycosis in high risk populations with prior antifungal prophylaxis.…”

An unusual opportunistic infection causing lower gastrointestinal tract bleeding in a patient with severe alcoholic hepatitis, post‐liver transplantation

“…In SAH, paradoxical “immune exhaustion” and an accumulation of other predisposing factors like steroids lead to an increased risk of IFIs and sepsis 6 . It is conceivable that in our patient, colonization and possible infiltration of the surgical site may have happened during exploratory laparotomy and progressed to invasive disease due to the recipient's inappropriate net immunosuppression status and targeted antifungal prophylaxis (TAP) with broad‐spectrum echinocandin therapy 7,8 …”

“…The initial evaluation revealed that the patient had acute severe alcoholic hepatitis (SAH) with grade 1 acute-on-chronic liver failure 6 It is conceivable that in our patient, colonization and possible infiltration of the surgical site may have happened during exploratory laparotomy and progressed to invasive disease due to the recipient's inappropriate net immunosuppression status and targeted antifungal prophylaxis (TAP) with broad-spectrum echinocandin therapy. 7,8 This case highlights several unmet needs in the management of SAH.…”