When medicine transforms art

Abstract

A 40-year-old female from Canada with a history of type 1 diabetes mellitus, diabetic retinopathy, and solitary pancreas transplant, presented with increase in her pancreatic enzymes 1-year post-transplant. Her induction immunosuppression consisted of anti-thymocyte globulin and maintenance immunosuppression at the time of her presentation was cyclosporine, mycophenolate mofetil and low-dose prednisone. Other medical history was significant for failed islet cell transplant in 2003 and prolonged neutropenia that later resolved with discontinuation of tacrolimus. Incidentally, a 1.1 cm right lower lobe cavity (Figure 1) was identified during her workup. A pancreas biopsy confirmed acute cellular rejection for which she was started on methylprednisolone. Upon interview with the patient, she reported extensive travel history that included parts of Central and South America, Africa, and Arizona in the United States. Her exposure history was also significant for frequent gardening and camping. Bronchoalveolar lavage from the right lower lobe revealed galactomannan index of 0.63. Serum galactomannan, serum cryptococcal antigen, Histoplasma, Blastomyces and Cococidioides serologies were all negative. Given the augmentation of immunosuppression, voriconazole was empirically started for possible invasive pulmonary aspergillosis pending final culture results. Shortly thereafter, she developed visual disturbances characterized by altered color perception with a purple predominance. Of note, voriconazole trough level was within therapeutic range at 2.0 mg/L. Potential drug-to-drug interactions were appropriately reviewed and cyclosporine dosing was reduced accordingly, with its level remaining within the target range. As the patient was a painter and continued painting throughout her hospitalization, significant changes in the colors of her paintings (Figures 2 and 3) were noted. The patient indicated she tried to reproduce the exact colors she perceived in her artwork. This resulted in a change of the color tones to purple. However, 2 weeks into voriconazole therapy, the respiratory specimen cultures grew Coccidioides immitis/posadasii (Figure 4) and thus voriconazole was switched to fluconazole with rapid resolution of her visual changes. The overall clinical picture was consistent with asymptomatic cavitation of a solitary coccidioidal pulmonary nodule. The patient remains clinically well on fluconazole 6 months post-pancreas graft rejection. Voriconazole has been reported to cause visual disturbances in approximately 30% of patients. 1 While photopsias are most Abstract A 40-year-old female with a history of type 1 diabetes mellitus and solitary pancreas transplant, presented with pancreatic graft rejection 1-year post-transplant. Incidentally, a 1.1 cm right lower lobe cavity was identified during her workup. Given the augmentation of immunosuppression, voriconazole was empirically started for possible invasive pulmonary aspergillosis. As the patient was a painter, this resulted in a significant change in the colors of h...

A Collaborative Tale of Diagnosing and Treating Chronic Pulmonary Aspergillosis, from the Perspectives of Clinical Microbiologists, Surgical Pathologists, and Infectious Disease Clinicians

“…One recent study demonstrated that voriconazole may be more effective than itraconazole [124]. However, voriconazole carries the risk of significant adverse effects, including neurotoxicity, phototoxicity, increased risk of dermatologic malignancies, and periostitis [125][126][127]. The phenomenon of accelerated metabolism (also referred to as autoinduction) that is particular to voriconazole requires attention and regular therapeutic drug monitoring [128].…”