Resolution of diffuse skin and systemic Kaposi's sarcoma in a renal transplant recipient after introduction of everolimus: a case report

Recurrent Subcutaneous Phaeohyphomycosis Due to Medicopsis romeroi: A Case Report in a Dermatomyositis Patient and Review of the Literature

Medicopsis romeroi phaeohyphomycosis is increasingly reported in immunocompromised patients living in or originating from tropical and subtropical areas. We report a case of subcutaneous phaeohyphomycosis caused by M. romeroi in a 56-year-old Malian woman residing in France for 20 years. She developed a small nodule on her dominant hand's ring finger 15 months after starting immunosuppressive medications for paraneoplastic dermatomyositis. A first surgical debridement was followed by a local recurrence. Despite a second surgical excision combined with posaconazole treatment, the infection recurred one year after antifungal therapy discontinuation. A wide excision was performed again, and antifungal therapy was resumed and maintained for six months, resulting in the absence of relapse during the 18 months following the surgery. This case highlighted the high risk of relapse in immunocompromised patients, suggesting the need for long-term follow-up and prolonged antifungal treatment following surgical excision in cases with sustained immunosuppression. The literature review was performed according to PRISMA guidelines and included 51 scientific publications. A noteworthy predominance of the subcutaneous phaeohyphomycosis presentation was found in immunocompromised patients, whereas eumycetoma had been reported in apparently healthy individuals. A combination of complete excision with antifungal treatment seemed to confer the best outcome.

Disseminated Medicopsis Romeroi Infection in a Kidney Transplant Recipient

Medicopsis romeroi is a rare, dematiaceous fungus that is difficult to identify using conventional fungal tests. Although uncommon, immunocompromised patients are particularly susceptible to this opportunistic fungus. Here, we report the case of a renal transplant recipient who presented with painful disseminated subcutaneous and soft tissue lesions. Sequencing of the Internal transcribed spacer (ITS) region of the ribosomal DNA identified the fungus as Medicopsis romeroi. Additionally, tissue samples from a non-healing wound on the left forearm grew Rhizopus spp. on Sabouraud dextrose agar, indicating a Mucormycosis superinfection. The patient's condition improved with surgical intervention and antifungal therapy with Posaconazole and Terbinafine. This case demonstrates the need for a high index of suspicion in order to facilitate early diagnosis and treatment and thus reduce the risk of dissemination.

Medicopsis romeroi nodular subcutaneous infection in a kidney transplant recipient

Phaeohyphomycosis is a set of fungal infections caused by various dematiaceous fungi such as coelomycetes. These infections can occur either in immunocompetent or immunocompromised patients like solid organ transplants. Here we describe a nodular lesion of the right hallux that occurred in a kidney transplant patient. Microscopic examination of the biopsy revealed fungal hyphae and culture was positive to a grey to black mould that lacked characteristic elements to be identified. Nucleic acid sequencing targeting the internal transcribed spacer of the ribosomal DNA identified this mould as Medicopsis romeroi. The patient benefited of an antifungal therapy with voriconazole associated with surgical excision of the lesion. No relapse of the lesion was observed during a six-month follow-up. In solid organ transplants, phaeohyphomycosis caused by Medicopsis romeroi are very rare with only 12 cases reported. The clinical history should be well assessed since the lesion can appear several years after a cutaneous trauma that happened in a tropical region. Therapy generally combines antifungals with surgical excision of the lesion in order to avoid any relapse or dissemination of the infection.

Kaposi Sarcoma Updates

Kaposi sarcoma (KS) is an angioproliferative mesenchymal neoplasm caused by Kaposi sarcoma-related herpesvirus. This review outlines our current understanding of the epidemiology, pathogenesis, clinical presentation, and staging for this disease. Recent research has informed a more comprehensive understanding of the epidemiology of KS in the post-antiretroviral therapy era, and highlights the continued need to better characterize the African endemic subtype. Advances in clinical oncology, including checkpoint inhibitors and new skin-directed therapies, have translated into exciting new developments for the future of KS treatment options.

Phaeohyphomycosis caused by Medicopsis romeroi in solid organ transplant recipients: Report of two cases and comprehensive review of the literature

Medicopsis romeroi is a melanized coelomycetous fungus, mainly found in tropical and subtropical regions and an uncommon cause of infection in solid organ transplant (SOT) recipients. We describe two cases of SOT recipients diagnosed with phaeohyphomycosis due to M romeroi and provide a comprehensive literature review. These infections should be considered in patients native to tropical countries with a localized skin and soft tissue infection. Sequencing is needed for accurate identification of uncommon melanized fungi. Surgical treatment is recommended to cure the infection and co-adjunctive oral antifungals should be considered.

Risk of Kaposi sarcoma after solid organ transplantation in the United States

Due to treatment with immunosuppressive medications, solid organ transplant recipients have elevated risk for Kaposi sarcoma (KS), which is caused by human herpesvirus 8 (HHV8). Other risk factors for KS are poorly understood. We linked the United States solid organ transplant registry with 17 population-based cancer registries to ascertain KS incidence among 244,964 transplant recipients from 1987-2014. To compare incidence rates of KS according to patient and transplant characteristics, we calculated incidence rate ratios (IRRs) using Poisson regression. To compare associations of KS with other skin cancers occurring before or within 12 months of KS diagnosis, we computed odds ratios (ORs) and 95% confidence intervals (CIs) using conditional logistic regression. All statistical tests were two-sided. We identified 163 KS cases during follow-up. Among transplant recipients, we found significantly increased risk of KS associated with male sex (IRR = 1.87; 95%CI:1.32,2.71), nonwhite race (IRR = 2.67; 95%CI:1.92,3.72), non-US citizenship (IRR = 2.10; 95%CI:1.19,3.47), lung transplant (IRR = 2.22; 95%CI:1.03,4.24, vs. kidney), and older age at transplant. KS risk decreased significantly with time since transplant and recent calendar year, however, no specific induction or maintenance medication was associated with KS. KS incidence was not significantly associated with ambient ultraviolet radiation (IRR = 1.32 95%CI:0.87,2.02, tertile 3 vs. 1). KS incidence has decreased in recent calendar years. In a cross-sectional sample, we found cutaneous squamous cell carcinoma was associated with KS (OR = 4.83; 95%CI:1.30,14.69). KS risk factors included those potentially associated with HHV8 infection and increased immunosuppression. Our findings suggest that transplant recipients with a non-KS skin cancer may also be at high KS risk.

Iatrogenic Kaposi's Sarcoma: a Retrospective Cohort Study in an Italian Tertiary Care Centre

AIMS

Kaposi's sarcoma (KS) is a lymphoangioproliferative multicentric disorder. Among its four distinct clinical variants, iatrogenic KS (iKS) typically affects patients who have received immunosuppressant regimens for organ transplants, proliferative disorders, or immune-mediated diseases. The aim of the current study was to examine the characteristics of a cohort of patients with iKS, evaluating the differences in terms of epidemiological and clinical features, management and outcomes between organ transplant recipients (OTR) and patients immunosuppressed for other medical conditions.

MATERIALS AND METHODS

This retrospective study included, out of 1389 KS patients, 143 patients suffering from iKS being followed in an Italian tertiary care centre from November 1995 to December 2016. Demographic data, clinical features, previous immunosuppressive therapies, management, and outcomes were recorded for each patient.

RESULTS

We detected iKS in 10.3% of the analysed KS population. The mean age was 71.9 years in non-OTR versus 51.4 years in OTR (P = 0.04). Staging at diagnosis showed a more severe disease in non-OTR than in OTR, with stage IA observed in 33.3% of OTR versus 11.8% of non-OTR (P < 0.001) and stage IVB in 29.1% of non-OTR versus 12.1% of OTR (P = 0.001). Corticosteroids represented the most frequent immunosuppressive drugs at diagnosis in both groups, in conjunction with cyclosporine A in OTR. Immunosuppressant reduction or withdrawal was carried out in 93.9% of OTR versus 63.6% of non-OTR (P < 0.001).

CONCLUSIONS

As corticosteroids and cyclosporine A are the most common iKS-inducing drugs, their reduction or withdrawal, wherever possible, is needed. Differences in disease severity at presentation between OTR and non-OTR may interfere with the choice of management strategy and the consequent outcome.

An Update on Kaposi's Sarcoma: Epidemiology, Pathogenesis and Treatment

Kaposi’s sarcoma is an angioproliferative neoplasm which has undergone considerable epidemiologic change since the original description by Moritz Kaposi in the late 1800s. This opportunistic neoplasm gained widespread notoriety within the US during the height of the AIDS epidemic, where it was frequently found co-occurring with opportunistic infections. With the advent of modern antiretroviral therapies, as well as an increasing number of individuals on immunosuppression for autoimmune disease or organ transplantation, the landscape of the immunocompromised individual has changed. It is now important for clinicians to be mindful of Kaposi’s sarcoma manifesting in a growing variety of clinical contexts.

Everolimus and Malignancy after Solid Organ Transplantation: A Clinical Update

Malignancy after solid organ transplantation remains a major cause of posttransplant mortality. The mammalian target of rapamycin (mTOR) inhibitor class of immunosuppressants exerts various antioncogenic effects, and the mTOR inhibitor everolimus is licensed for the treatment of several solid cancers. In kidney transplantation, evidence from registry studies indicates a lower rate of de novo malignancy under mTOR inhibition, with some potentially supportive data from randomized trials of everolimus. Case reports and small single-center series have suggested that switch to everolimus may be beneficial following diagnosis of posttransplant malignancy, particularly for Kaposi's sarcoma and nonmelanoma skin cancer, but prospective studies are lacking. A systematic review has shown mTOR inhibition to be associated with a significantly lower rate of hepatocellular carcinoma (HCC) recurrence versus standard calcineurin inhibitor therapy. One meta-analysis has concluded that patients with nontransplant HCC experience a low but significant survival benefit under everolimus monotherapy, so far unconfirmed in a transplant population. Data are limited in heart transplantation, although observational data and case reports have indicated that introduction of everolimus is helpful in reducing the recurrence of skin cancers. Overall, it can be concluded that, in certain settings, everolimus appears a promising option to lessen the toll of posttransplant malignancy.

Elucidation of the mTOR Pathway and Therapeutic Applications in Dermatology

The member of the phosphatidylinositol 3-kinase family, mammalian target of rapamycin, is involved in modulating inflammatory response and regulating cellular processes associated with growth, differentiation, and angiogenesis. Recent years have seen major advances in our understanding of the mammalian target of rapamycin signaling pathway and the implication of this pathway in multiple genetic and inflammatory diseases and tumors. The development of the mammalian target of rapamycin inhibitors has given rise to new treatment approaches that have led to substantially improved outcomes in many diseases. In this article, we review the role of the mammalian target of rapamycin signaling pathway in the different skin diseases with which it has been associated, examine the therapeutic applications of drugs targeting this pathway, and provide an overview of current trends and future directions in research.

Post-transplantation malignancies: here today, gone tomorrow?

From the early days of transplantation onwards, increased cancer development in transplant recipients, who require immunosuppression to avoid graft rejection, has been recognized. Registry data indicate that approximately 10-30% of deaths are attributed to post-transplant malignancy, with an upward trend in this incidence as more patients have been exposed to chronic lifelong immunosuppression. In this Review, the overall incidence and most frequent types of cancer encountered are summarized, along with information about which transplant recipients are at the greatest risk of malignancy. Reasons for why differences exist in susceptibility to cancer in this patient population are examined, and approaches that might improve our understanding of the options available for reducing the incidence of this adverse effect of immunosuppression are described. Whether anti-rejection drugs have been successful in diminishing overall immunosuppressive burden, and consequently show any promise for decreasing post-transplant malignancies is also discussed. The topic shifts to one class of conventional anti-rejection drugs, the mammalian target of rapamycin (mTOR) inhibitors, which paradoxically have both immunosuppressive and anti-neoplastic properties. The complex activities of mTOR are reviewed in order to provide context for how these seemingly opposing effects are possible, and the latest clinical data on use of mTOR inhibitors in the clinic are discussed. The current and future perspectives on how best to normalize these unacceptably high rates of post-transplantation malignancies are highlighted.