J Korean Soc Transplant.  2010 Mar;24(1):35-39. 10.4285/jkstn.2010.24.1.35.

A Case of Successful Treatment of Cutaneous Aspergillosis with Voriconazole at the Low Cyclosporine Trough Level in a Renal Transplant

• Park SJ

• KMID: 2202222
• DOI: http://doi.org/10.4285/jkstn.2010.24.1.35

Abstract

Aspergillosis is a serious infectious complication with high mortality in transplant recipients. Voriconazole is a broad spectrum triazole antifungal agent, but it has a drug-drug interaction with immunosuppressants. Herein we report a case of the use of a small dose of cyclosporine (CsA) with coadministration of voriconazole. A 23 year old woman received a kidney transplant from a deceased donor. The initial immunosuppressant was tacrolimus, mycophenolate mofetil, steroids, and basiliximab. Thirty-two days after kidney transplantation, because of hemolytic uremic syndrome, she received Rabbit anti-human thymocyte immunoglobulin and plasmapheresis. Cyclosporine was used instead of tacrolimus. Three months after transplantation, she was admitted to the hospital because of an erythematous nodule on her trunk and a dry cough. Skin biopsy revealed an Aspergillus species and tissue culture showed that it was A. fumigatus. We treated her with itraconazole and subsequently with amphotericin B. Afterwards, her condition got worse. So we changed amphotericin B to voriconazole and a minimum dose of CsA (25 mg bid) at the peril of graft failure. Eventually, she recovered and maintained good graft function. The trough level of CsA ranged from 3.2 to 27.9 ng/mL.

Keyword

Aspergillus; Cyclosporine; P-glycoprotein

MeSH Terms

Amphotericin B
Antibodies, Monoclonal
Aspergillosis
Aspergillus
Biopsy
Cough
Cyclosporine
Female
Hemolytic-Uremic Syndrome
Humans
Immunoglobulins
Immunosuppressive Agents
Itraconazole
Kidney
Kidney Transplantation
Mycophenolic Acid
P-Glycoprotein
Plasmapheresis
Pyrimidines
Recombinant Fusion Proteins
Skin
Steroids
Tacrolimus
Thymocytes
Tissue Donors
Transplants
Triazoles
Amphotericin B
Antibodies, Monoclonal
Cyclosporine
Immunoglobulins
Immunosuppressive Agents
Itraconazole
Mycophenolic Acid
P-Glycoprotein
Pyrimidines
Recombinant Fusion Proteins
Steroids
Tacrolimus
Triazoles

Figure

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  Fig. 1. Erythematous subcutaneous nodules located on the trunk.

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  Fig. 2. Thoracic computed tomography showing nodular lesions in the right lung parenchyma which was suggestive of fungal infection.

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  Fig. 3. Skin biopsy demonstrating fungal hyphae with acute angle branching consistent with Aspergillus (hematoxylin-eosin staining; ×400).

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  Fig. 4. The clinical course of patient demonstrates the good allograft function with low blood concentration of CsA. Abbreviations: CsA, cyclosporine A; b.i.d, bis in die; PDS, pre-dnisolone AmB, amphotericin B; s-Cr, serum-creatinin BT, body temperature.

Reference

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