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Barrios EL, Drabick Z, Rodriguez J, Fahy BG, Cochran AL, Driscoll IR, Munden AM. Precision Medicine Approach Using Triple Combination Antifungal Therapy for Fusarium Brain Abscesses and Endocarditis in an Adult Burn Patient. Mil Med 2024:usae284. [PMID: 38836840 DOI: 10.1093/milmed/usae284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/16/2024] [Accepted: 05/17/2024] [Indexed: 06/06/2024] Open
Abstract
We report a management strategy for disseminated Fusarium solani fungal infection in an adult 35% total body surface area burn patient with brain abscesses and concomitant pulmonic valve endocarditis resulting in the longest survival reported in a burn patient. Early in his hospital course, the patient was diagnosed with a Fusarium burn wound infection with concomitant fungemia and was treated with a prolonged course of intravenous (IV) antifungal monotherapy. Shortly thereafter, he developed focal neurologic deficits and was found to have brain abscesses on MRI. He underwent emergent craniotomy with debridement, and triple antifungal therapy was initiated. Transesophageal echocardiography demonstrated pulmonic valve vegetations, which resolved with triple antifungal therapy. Disseminated Fusarium solani infection is quite rare with mortality approaching 100%. Given the rarity of this disease process, there are no established antifungal treatment guidelines. However, this patient survived for approximately 1 year after diagnosis with treatment including source control via craniotomy and debridement coupled with prolonged courses of combination antifungal therapy (given the near pan-resistance of his fungal infection). Pharmacogenomic testing was utilized to establish the patient's metabolism of voriconazole and dosing adjusted accordingly to improve the efficacy of the combination therapy. To our knowledge, an adult burn patient surviving this length of time after Fusarium brain abscesses with disseminated infection has not been previously described.
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Affiliation(s)
- Evan L Barrios
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610-0108, USA
| | - Zachary Drabick
- Department of Pharmacy, UF Health Shands Hospital, Gainesville, FL 32608, USA
| | - John Rodriguez
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610-0108, USA
| | - Brenda G Fahy
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL 32610-0254, USA
| | - Amalia L Cochran
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610-0108, USA
| | - Ian R Driscoll
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610-0108, USA
| | - Andrea M Munden
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610-0108, USA
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Hoenigl M, Jenks JD, Egger M, Nucci M, Thompson GR. Treatment of Fusarium Infection of the Central Nervous System: A Review of Past Cases to Guide Therapy for the Ongoing 2023 Outbreak in the United States and Mexico. Mycopathologia 2023; 188:973-981. [PMID: 37653167 PMCID: PMC10687128 DOI: 10.1007/s11046-023-00790-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023]
Abstract
INTRODUCTION Fusariosis of the central nervous system (CNS) is extremely uncommon. Treatment and outcome data from previously published cases may provide some guidance in light of the ongoing fungal meningitis outbreak in 2023 involving Fusarium spp. in the United States and Mexico. METHODS We reviewed the published literature describing cases of invasive fusariosis of the (CNS) that included data on patient demographic characteristics, treatment, and outcome. RESULTS Twenty-six cases met inclusion criteria. The mean age was 36 years, 55% involved females, 60% had underlying hematologic malignancy, and another 16% were on immunosuppressants. The majority of infections were from Fusarium solani species complex. Overall 72% of patients died. The majority received monotherapy with amphotericin B, although some received voriconazole monotherapy or combination therapy with amphotericin B plus voriconazole with or without adjuvant surgery. Among the survivors, 3 received amphotericin B monotherapy, 2 voriconazole monotherapy, 1 combination therapy of both, and one surgery only. CONCLUSION The overall mortality rate in published cases of fusariosis of the CNS was high, although-unlike during the current outbreak-the preponderance of patients were severely immunocompromised. While historically the majority were treated with amphotericin B monotherapy, some recent patients were treated with voriconazole monotherapy or combination therapy with amphotericin B plus voriconazole. Current guidelines recommend monotherapy with voriconazole or lipid formulations of amphotericin B or combination of both for the treatment of invasive fusariosis, which is in line with the findings from our literature review and should be considered during the ongoing 2023 outbreak.
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Affiliation(s)
- Martin Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
- BioTechMed, Graz, Austria.
| | - Jeffrey D Jenks
- Durham County Department of Public Health, Durham, NC, USA
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, NC, USA
| | - Matthias Egger
- Division of Infectious Diseases, Department of Internal Medicine, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
- BioTechMed, Graz, Austria
| | - Marcio Nucci
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
- Grupo Oncoclinicas, Rio de Janeiro, RJ, Brazil
| | - George R Thompson
- University of California Davis Center for Valley Fever, Davis, CA, USA.
- Division of Infectious Diseases, Department of Internal Medicine, University of California Davis Medical Center, University of California-Davis Health, 1450 V Street, Suite G500, Sacramento, CA, USA.
- Department of Medical Microbiology and Immunology, University of California Davis, Davis, CA, USA.
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Stevens A, Waldrop C, Mandell S, Abdelfattah K, Arnoldo B, Akarichi CO, Clark AT. Fungal brain abscess in a severely burned patient. J Burn Care Res 2023; 44:1253-1257. [PMID: 37486798 DOI: 10.1093/jbcr/irad111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Indexed: 07/26/2023]
Abstract
Burn patients are particularly susceptible to atypical and opportunistic infections. Here we report an unusual case of a 40-year-old previously healthy man with a 74% TBSA burn injury who developed a presumed Fusarium brain abscess. This patient had a complicated infectious course including ESBL E. coli and Elizabethkingia bacteremia and pneumonia, MRSA ventilator-associated pneumonia, Mycobacterium abscessus bacteremia, and Fusarium fungemia. After diagnosis with a fungal abscess on magnetic resonance imaging of the brain, the patient was treated with aspiration and appropriate antifungal therapies. The patient was eventually transitioned to comfort care and died on hospital day 167. This is the first published report of a Fusarium-related brain abscess since it was first reported in a case report of a burned child in 1974.
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Affiliation(s)
- Audrey Stevens
- Department of Surgery, Parkland Health and Hospital System, Dallas, TX, USA
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Caitlyn Waldrop
- Department of Surgery, Parkland Health and Hospital System, Dallas, TX, USA
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Samuel Mandell
- Department of Surgery, Parkland Health and Hospital System, Dallas, TX, USA
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kareem Abdelfattah
- Department of Surgery, Parkland Health and Hospital System, Dallas, TX, USA
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Brett Arnoldo
- Department of Surgery, Parkland Health and Hospital System, Dallas, TX, USA
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Chiaka O Akarichi
- Department of Surgery, Parkland Health and Hospital System, Dallas, TX, USA
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Audra T Clark
- Department of Surgery, Parkland Health and Hospital System, Dallas, TX, USA
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Kao AS, Cramer-Bour C, Kupsky W, Soubani AO. Endophthalmitis as the initial manifestation of invasive fusariosis in an allogeneic stem cell transplant patient: A case report. Med Mycol Case Rep 2023; 40:5-7. [PMID: 36873422 PMCID: PMC9982450 DOI: 10.1016/j.mmcr.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/30/2023] [Accepted: 02/13/2023] [Indexed: 02/22/2023] Open
Abstract
Fusarium species manifests as an opportunistic infection with intrinsic resistance to most antifungals. We present a case of a 63-year-old male with myelodysplasia who received allogeneic stem cell transplantation and presented with endophthalmitis as the initial manifestation of invasive fusariosis that progressed to a fatal outcome despite combined intravitreal and systemic antifungal therapies. We urge clinicians to consider this complication of fusarium infection especially with the widespread use of antifungal prophylaxis that may incur selection of more resistant, invasive fungal species.
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Affiliation(s)
- Andrew S Kao
- Wayne State University School of Medicine, 540 E. Canfield St, Detroit, 48201, United States
| | - Cassondra Cramer-Bour
- Detroit Medical Center, Department of Pulmonary and Critical Care Medicine, 3990 John R- 3 Hudson, Detroit, MI, 48201, United States
| | - William Kupsky
- Detroit Medical Center, Department of Pathology, 4201 St Antoine, Detroit, MI, 48201, United States
| | - Ayman O Soubani
- Detroit Medical Center, Department of Pulmonary and Critical Care Medicine, 3990 John R- 3 Hudson, Detroit, MI, 48201, United States
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