Sporotrichosis in renal transplant patients: two case reports and a review of the literature

Abstract

Introduction: Sporotrichosis is a rare fungal infection in transplant patients; among these patients, it occurs mostly in renal transplant patients. Sporothrix schenkii is the primary pathogen responsible. A high index of suspicion is required to make the diagnosis keeping important differential diagnoses in mind. History of trauma through recreational or occupational exposure to the fungus may assist in making the diagnosis. Treatment is difficult, with long-term use of potentially nephrotoxic and cytochrome P450 inhibitor antifungal agents leading to potential calcineurin inhibitors toxicity. We describe two renal transplant patients presenting with distinct sporotrichosis infection: "Case 2" being only the second reported case ever of meningeal sporotrichosis. We subsequently review the general aspects of sporotrichosis, specifically in renal transplant patients as described in the medical literature. Case presentation: Case 1, a 43-year-old mixed ancestry male patient presented with a non-healing ulcer on the left arm for 1 year, he was diagnosed with cutaneous sporotrichosis and was successfully treated with itraconazole monotherapy. Case 2, a 56-year-old mixed ancestry male patient presented with a slow decline in functions, confusion, inappropriate behavior, rigors and significant loss of weight and appetite over the past 4 months, he was diagnosed with meningeal sporotrichosis and was successfully treated with a combination of deoxycholate amphotericin B and itraconazole. Conclusion: Physicians taking care of renal transplant patients should have a high index of suspicion for sporotrichosis infection particularly when conventional therapy for common conditions fails. Susceptibility testing is recommended to identify the most effective antifungal agent and its dose. The slow nature of growth of Sporothrix schenkii necessitates patients to be on amphotericin B until the time results are available. Finally, there is a need to be aware of potential drug-drug interactions of the azoles with calcineurin inhibitors and the required dose adjustments to prevent therapy related adverse events.

Human sporotrichosis: recommendations from the Brazilian Society of Dermatology for the clinical, diagnostic and therapeutic management

“… 100 Amphotericin B is the main drug used to treat severe, visceral, and life-threatening systemic sporotrichosis, although the therapeutic response is not as favorable as in other systemic mycoses. 2 , 48 , 98 , 115 Treatment maintenance after the administration of amphotericin B is usually carried out with itraconazole for a period of 12 months. Lipid formulations of amphotericin B constitute a more tolerable alternative to the conventional one; however, their superiority in terms of efficacy has not been proven for sporotrichosis.…”

“…Amphotericin B is the main drug used to treat severe, visceral, and life-threatening systemic sporotrichosis, although the therapeutic response is not as favorable as in other systemic mycoses. 2 , 48 , 98 , 115 Treatment maintenance after the administration of amphotericin B is usually carried out with itraconazole for a period of 12 months.…”

Zoonotic sporotrichosis in renal transplant recipients from Rio de Janeiro, Brazil

“…Extracutaneous and disseminated forms were described in seven of the nine cases of sporotrichosis in renal transplant recipients previously reported in the literature (Table 2). 6,13‐18 Species differentiation was available in just one of them, in which S scheckii was identified by polymerase chain reaction sequencing 18 . This is in part because of the majority of these articles were previous to the new taxonomy of Sporothrix spp that recognized new species of the agent.…”

“…Although most of these patients cured, difficult clinical decisions were remarkable. The need of discontinuation of immunosuppressive treatment in order to control the infection, 13,14,18 amphotericin nephrotoxicity leading to hemodialysis, 14 and recurrence of sporotrichosis reported in five of the nine cases 13‐15,18 . Azotemia occurs in 80% of patients who receive AMB for deep mycoses, with dose‐dependent toxicity.…”

Antifungal Drugs TDM: Trends and Update

“…AF TDM cases in real-life settings (pathogens, underlying diseases, 69,71–73,75,81 trends per year, 84,234,235,236,238,239,241,244,245,344–348 CNS 532–539 localization 541–566 ) 364,370,499,522,527–530 Trends are concerning a majority of mucomycosis and aspergillosis, in oncohematology and transplantation. VRZ, more recently PSZ tablets and ISZ are the most represented.…”