Deep sinus aspergillosis in a liver transplant recipient successfully treated with a combination of caspofungin and voriconazole (original) (raw)

2004, Transplant Infectious Disease

We describe the rare case of a diabetic patient who was successfully treated for cytomegalovirus viremia and leishmaniasis following liver transplantation for hepatitis C virus-related cirrhosis, but also developed invasive sinus Aspergillus infection, while still on liposomal amphotericin B (AmBisome). The patient refused radical surgery including eye enucleation, and received a combination of intravenous caspofungin and voriconazole, along with repeated, conservative, local surgical debridement. At follow-up, 15 months after the onset of sinusitis, the patient remains culture-negative, fully active, and without evidence of local recurrence. Infection with Aspergillus species results in excess mortality rates ranging from 58% to 87% in immunosuppressed patients including organ transplant recipients (1, 2). Traditionally, the standard deoxycholate formulation of amphotericin B has been used in immunocompromised patients with invasive aspergillosis (3) with suboptimal results and signi¢cant toxicity associated with its use. Recently liposomal formulations, when available, have been preferentially used over the traditional formulation in clinical practice. The traditional amphotericin B regimen has been recently shown to be less e¡ective for invasive aspergillosis than therapy with the newer antifungal voriconazole (4). Caspofungin acetate belongs to the newer class of antifungal agents, the echinocandins. Good in vivo and in vitro results against Aspergillus infections have earned its approval for use in refractory invasive Aspergillus infections (5). Combination of antifungals has been reserved for refractory cases only. However, combination therapy may have an important role in treating invasive aspergillosis as a primary option and not as a last resort (6). It is important to note that recently, in vitro synergistic e¡ects have been shown between newer and more traditional antifungal agents (6, 7). Recent trials in invasive fungal infections have shown that combining either caspofungin or voriconazole with amphotericin B has a clear clinical