Two Cases of Pulmonary Aspergillosis Successfully Treated with Combinated Micafungin and Itraconazole Therapy

Abstract

We report 2 cases of pulmonary aspergillosis treated successfully by combining micafungin and traconazole. Case 1: A 51-year-old man with hemoptysis and dyspnea on effort treated for pulmonary tuberculosis and aspergillosis was found on chest CT on admission to have a fungus ball in the left upper lobe and increasing consolidation around the cavity of both lung fields. Bronchoscopy proved positive for aspergillus PCR in bronchial lavage. He was diagnosed with chronic necrotizing pulmonary aspergillosis, based on clinical and radiological findings and the positive reaction for aspergillus PCR. He was treated with micafungin alone at first, this proved ineffective, so itraconazole was added, resulting in improvement. Case 2: A 24-year-old woman with stabilized Hodgkin's disease (mixed). She had suffered from a cough and back pain, and chest CT showed increasing consolidation inside and around a giant bulla. She was diagnosed with chronic necrotizing pulmonary aspergillosis, based on isolation for Aspergillus sp. in sputum culture and a positive reaction for Aspergillus antigen in bronchial lavage and Aspergillus antibody in serum. She was treated with the combined micafungin and itraconazole, which rapidly improved symptoms and radiological findings. Pulmonary aspergillosis therapy is often difficult, because delivery of the drug to the infection site is limited and drug tolerance is poor. We found that combination micafungin and itraconazole therapy is tolerable and effective in these cases.

In vitro interactions of itraconazole and micafungin against clinically important filamentous fungi

“…This could be especially interesting in critically ill patients. Although combined therapy with MFG + ITC has been used successfully in the treatment of human pulmonary aspergillosis [9,10], the available data on the in vitro and experimental interactions between ITC and echinocandins are contradictory. Philip et al [19] reported synergistic in vitro interactions between ITC and other echinocandins, such as anidulafungin, against A. fumigatus and A. flavus.…”

“…Echinocandins are a novel group of antifungal drugs that may show synergy with other drug classes such as azoles against refractory fungi [8]. Some clinical data have suggested the use of micafungin (MFG), an echinocandin, combined with itraconazole (ITC), an azole, in the treatment of fungal infections [9,10] use of ITC are its cheaper cost and the advent of promising new formulations. The purpose of this study was to evaluate the in vitro interactions between MFG and ITC against clinically important filamentous fungi.…”

Papel futuro de la micafungina en el tratamiento de las micosis invasoras por hongos filamentosos

“…Si bien hay poca evidencia de micafungina en la AI, en los trabajos publicados se ha demostrado su eficacia tanto en estudios clínicos 18 , como en casos o series de casos publicados 30,45,56,[64][65][66][67]81,90 , la mayoría en combinación con azoles, y no hay ningún ensayo clínico ni estudio aleatorizado publicado hasta el momento que lo trate, salvo un trabajo de perfil farmacocinético realizado en pacientes críticos en una UCI japonesa, que se comentará mas adelante 38 . Sin embargo, hay varias consideraciones ligadas al entorno crítico que deberían tenerse en cuenta a favor de micafungina, la cual presenta una actividad excelente in vitro frente a hongos filamentosos 5 y sinergismos, tanto in vitro, como en modelos animales 35,79,84,85 , con la mayoría de los antifúngicos comercializados y, en especial, con los azoles (itraconazol y voriconazol).…”