Fatal Fusarium infection manifesting as osteomyelitis following previous treatment with amphotericin B in a multi-visceral transplant: Case report and review of Fusarium infections in solid organ transplantation

Efficacy assessments of SF001, a next-generation polyene antifungal, in a neutropenic mouse model of invasive fusariosis

Fusariosis has high mortality rates with limited treatment options. Owing to its rarity, comparative clinical trials are hard to perform. SF001 is a novel, next-generation polyene drug, rationally designed to reduce potential for systemic toxicity, with long-acting, potent, broad-spectrum fungicidal activity. We compared the in vitro activity and in vivo efficacy of SF001 with liposomal amphotericin B (LAMB) in treating immunosuppressed mice infected with hematogenously disseminated fusariosis. The minimum inhibitory concentration (MIC) of SF001 and LAMB against Fusarium solani or Fusarium oxysporum strains (at 100% inhibition) ranged between 0.5-8 µg/mL and 1->16 µg/mL, respectively. In the hematogenously disseminated fusariosis model, treatment with SF001 or LAMB enhanced the median survival time vs placebo (7, 10, and 9 days at 3, 7.5, and 30 mg/kg of SF001, respectively, and 12.5 days for LAMB at 7.5 mg/kg vs 6.5 days for placebo, P < 0.0001). SF001 and LAMB treatment enhanced the overall survival by day 21 (40% and 25% for SF001 at 7.5 mg/kg and 30 mg/kg, respectively, 30% for LAMB at 7.5 mg/kg and 0% for placebo). The survival data were mirrored in the kidney and brain fungal burden results with ~2-3 log10 reduction in conidial equivalents/gram for either treatment vs placebo. Furthermore, the reduction in tissue fungal burden was corroborated by histopathological data from target organs, showing reduced or no abscesses in SF001- or LAMB-treated mice. Our data show comparable activity of SF001 to LAMB, thereby supporting the continued development of SF001 for the treatment of invasive fusariosis.

Case Report: Fusarium falciforme pericardial and sternal wound infection following orthotopic heart transplantation

Fusarium, a genus of soil and vegetation-based fungi, is a rare cause of infections in immunocompromised individuals, including transplant recipients. In this case, we describe successful treatment of Fusarium falciforme mediastinitis in the recipient of an orthotopic heart transplant. Treatment included multiple courses of combination antibiotic and antifungal therapy several surgical debridements, continuous mediastinal irrigation with antifungal agents, and staged closure with an omental flap. This is the first report describing successful eradication of fusarium sp. mediastinitis and provides a template for treating complex cases of mediastinitis and osteomyelitis.

Invasive fusariosis

Invasive fusariosis is a serious invasive fungal disease, affecting immunocompetent and, more frequently, immunocompromised patients. Localized disease is the typical clinical form in immunocompetent patients. Immunocompromised hosts at elevated risk of developing invasive fusariosis are patients with acute leukemia receiving chemotherapeutic regimens for remission induction, and those undergoing allogeneic hematopoietic cell transplant. In this setting, the infection is usually disseminated with positive blood cultures, multiple painful metastatic skin lesions, and lung involvement. Currently available antifungal agents have poor in vitro activity against Fusarium species, but a clear-cut correlation between in vitro activity and clinical effectiveness does not exist. The outcome of invasive fusariosis is largely dependent on the resolution of immunosuppression, especially neutrophil recovery in neutropenic patients.

Pneumocystis jirovecii Pneumonia after Heart Transplantation: Two Case Reports and a Review of the Literature

Post-transplant Pneumocystis jirovecii pneumonia (PcP) is an uncommon but increasingly reported disease among solid organ transplantation (SOT) recipients, associated with significant morbidity and mortality. Although the introduction of PcP prophylaxis has reduced its overall incidence, its prevalence continues to be high, especially during the second year after transplant, the period following prophylaxis discontinuation. We recently described two cases of PcP occurring more than one year after heart transplantation (HT) in patients who were no longer receiving PcP prophylaxis according to the local protocol. In both cases, the disease was diagnosed following the diagnosis of a viral illness, resulting in a significantly increased risk for PcP. While current heart transplantation guidelines recommend Pneumocystis jirovecii prophylaxis for up to 6-12 months after transplantation, after that period they only suggest an extended prophylaxis regimen in high-risk patients. Recent studies have identified several new risk factors that may be linked to an increased risk of PcP infection, including medication regimens and patient characteristics. Similarly, the indication for PcP prophylaxis in non-HIV patients has been expanded in relation to the introduction of new medications and therapeutic regimens for immune-mediated diseases. In our experience, the first patient was successfully treated with non-invasive ventilation, while the second required tracheal intubation, invasive ventilation, and extracorporeal CO2 removal due to severe respiratory failure. The aim of this double case report is to review the current timing of PcP prophylaxis after HT, the specific potential risk factors for PcP after HT, and the determinants of a prompt diagnosis and therapeutic approach in critically ill patients. We will also present a possible proposal for future investigations on indications for long-term prophylaxis.

Successful Use of Fosmanogepix for Treatment of Rare Highly Resistant Cutaneous Fusariosis in a Pediatric Patient With STAT3 Hyper-Immunoglobulin E Syndrome and End-Stage Kidney Disease

We describe the successful use of the novel antifungal drug fosmanogepix to treat a chronic case of multidrug-resistant cutaneous Fusarium suttonianum infection in a pediatric patient with STAT3 hyper-IgE syndrome and end-stage kidney disease on peritoneal dialysis.

Non-Aspergillus Hyaline Molds: A Host-Based Perspective of Emerging Pathogenic Fungi Causing Sinopulmonary Diseases

The incidence of invasive sino-pulmonary diseases due to non-Aspergillus hyaline molds is increasing due to an enlarging and evolving population of immunosuppressed hosts as well as improvements in the capabilities of molecular-based diagnostics. Herein, we review the following opportunistic pathogens known to cause sinopulmonary disease, the most common manifestation of hyalohyphomycosis: Fusarium spp., Scedosporium spp., Lomentospora prolificans, Scopulariopsis spp., Trichoderma spp., Acremonium spp., Paecilomyces variotii, Purpureocillium lilacinum, Rasamsonia argillacea species complex, Arthrographis kalrae, and Penicillium species. To facilitate an understanding of the epidemiology and clinical features of sino-pulmonary hyalohyphomycoses in the context of host immune impairment, we utilized a host-based approach encompassing the following underlying conditions: neutropenia, hematologic malignancy, hematopoietic and solid organ transplantation, chronic granulomatous disease, acquired immunodeficiency syndrome, cystic fibrosis, and healthy individuals who sustain burns, trauma, or iatrogenic exposures. We further summarize the pre-clinical and clinical data informing antifungal management for each pathogen and consider the role of adjunctive surgery and/or immunomodulatory treatments to optimize patient outcome.

Disseminated fusarium infection after allogeneic hematopoietic stem cell transplantation after CART: A case report

BACKGROUND

Fusarium is a conditional pathogen that can cause invasive infection in patients with hematological diseases under immune function.

METHODS

A case of recurrent and refractory Philadelphia chromosome-positive acute lymphoblastic leukemia was treated with allogeneic hematopoietic stem cell transplantation after chimeric antigen receptor-modified T cells treatment.

RESULTS

During transplantation, disseminated Fusarium infection occurred, involving the skin, liver, spleen and central nervous system, and the patient eventually died.

CONCLUSIONS

Early identification of Fusarium infection based on the characteristic rash and timely antifungal treatment can improve the cure rate.

Disseminated Fusarium bloodstream infection in a child with acute myeloid leukemia: A case report

BACKGROUND

Disseminated Fusarium is rare in healthy children. Children with hematological tumors may have secondary fungal infections, including Fusarium infections, which are due to tumor bone marrow infiltration or prolonged bone marrow suppression after chemotherapy. Because of the lack of typical clinical manifestations and effective antifungal drugs, early diagnosis and treatment of the disease are difficult, and the prognosis is poor.

CASE SUMMARY

The patient in this case was a 13-year-old female child with rash and fever as the first symptoms. She had the characteristics of the four stages of skin that are typical of Fusarium infection. She was diagnosed with disseminated Fusarium infection through skin biopsy and blood culture and diagnosed with Fusarium solani infection based on the morphological characteristics of the blood culture. After treatment with liposome amphotericin B combined with voriconazole, the child recovered.

CONCLUSION

This case highlights that for children with secondary agranulocytosis after receiving chemotherapy for hematological malignancies, once typical abnormal skin damage is found, the possibility of Fusarium infection should be considered, and voriconazole alone or in combination with polyenes may be the most effective anti-Fusarium drugs. Amphotericin B, the traditional drug of disseminated Fusarium disease, has a high mortality rate, and it is not recommended to use it alone. Adequate neutrophil counts are essential for the treatment of disseminated Fusarium bloodstream infection.

Isolated pulmonary fusariosis caused by Neocosmospora pseudensiformis in a liver transplant recipient: A case report and review of the literature

Neocosmospora pseudensiformis (formerly Fusarium pseudensiforme) is a hyaline mold in the Fusarium solani species complex that has been changed to the genus Neocosmospora. Invasive fusariosis is a rare fungal infection in solid organ transplantation. The most commonly reported manifestation of invasive fusariosis in this setting is localized cutaneous fusariosis. Here, we present the first case report of isolated N pseudensiformis pulmonary infection in a patient with non-alcoholic steatohepatitis cirrhosis who underwent orthotopic liver transplantation. A 67-year-old Thai woman developed acute graft rejection, dyspnea, and pulmonary consolidation 6 months after liver transplantation. N pseudensiformis was isolated from her sputum, and her clinical symptoms were improved with voriconazole treatment. However, she succumbed to Acinetobacter baumannii hospital-acquired pneumonia and acute coronary syndrome with cardiogenic shock after 10 days of treatment.

Emerging fungal infections in solid organ transplant recipients: Guidelines of the American Society of Transplantation Infectious Diseases Community of Practice

These updated AST-IDCOP guidelines review the epidemiology, diagnosis, and management of emerging fungi after organ transplantation. Infections due to numerous generally innocuous fungi are increasingly recognized in solid organ transplant (SOT) recipients, comprising about 7%-10% of fungal infections in this setting. Such infections are collectively referred to as emerging fungal infections and include Mucormycetes, Fusarium, Scedosporium, and dematiaceous fungi among others. The causative organisms are diverse in their pathophysiology, uncommon in the clinical setting, have evolving nomenclature, and are often resistant to multiple commonly used antifungal agents. In recent years significant advances have been made in understanding of the epidemiology of these emerging fungal infections, with improved diagnosis and expanded treatment options. Still, treatment guidelines are generally informed by and limited to experience from cohorts of patients with hematological malignancies and/or solid and stem cell transplants. While multicenter randomized controlled trials are not feasible for these uncommon infections in SOT recipients, collaborative prospective studies can be valuable in providing information on the epidemiology, clinical manifestations, treatment strategies, and outcomes associated with the more commonly encountered infections.