Sporotrichosis in Renal Transplant Patients

Two Case Reports and a Review of the Literature

Mazhar Hussein Amirali; Jacques Liebenberg; Sheylyn Pillay; Johan Nel

Disclosures

J Med Case Reports. 2020;14(79) 

In This Article

Abstract and Introduction

Abstract

Introduction: Sporotrichosis is a rare fungal infection in transplant patients; among these patients, it occurs mostly in renal transplant patients. Sporothrix schenkii is the primary pathogen responsible. A high index of suspicion is required to make the diagnosis keeping important differential diagnoses in mind. History of trauma through recreational or occupational exposure to the fungus may assist in making the diagnosis. Treatment is difficult, with long-term use of potentially nephrotoxic and cytochrome P450 inhibitor antifungal agents leading to potential calcineurin inhibitors toxicity. We describe two renal transplant patients presenting with distinct sporotrichosis infection: "Case 2" being only the second reported case ever of meningeal sporotrichosis. We subsequently review the general aspects of sporotrichosis, specifically in renal transplant patients as described in the medical literature.

Case presentation: Case 1, a 43-year-old mixed ancestry male patient presented with a non-healing ulcer on the left arm for 1 year, he was diagnosed with cutaneous sporotrichosis and was successfully treated with itraconazole monotherapy. Case 2, a 56-year-old mixed ancestry male patient presented with a slow decline in functions, confusion, inappropriate behavior, rigors and significant loss of weight and appetite over the past 4 months, he was diagnosed with meningeal sporotrichosis and was successfully treated with a combination of deoxycholate amphotericin B and itraconazole.

Conclusion: Physicians taking care of renal transplant patients should have a high index of suspicion for sporotrichosis infection particularly when conventional therapy for common conditions fails. Susceptibility testing is recommended to identify the most effective antifungal agent and its dose. The slow nature of growth of Sporothrix schenkii necessitates patients to be on amphotericin B until the time results are available. Finally, there is a need to be aware of potential drug-drug interactions of the azoles with calcineurin inhibitors and the required dose adjustments to prevent therapy related adverse events.

Introduction

Sporotrichosis is a rare fungal infection in transplant patients and among these patients it occurs mostly in renal transplant patients. Extracutaneous forms of sporotrichosis – including meningeal sporotrichosis – without skin manifestations and no previous history of traumatic injuries have been described and are often difficult to diagnose. We present two renal transplant patients who presented with sporotrichosis, case 1 with cutaneous sporotrichosis, the most common presentation, and case 2 with meningeal sporotrichosis, which is exceedingly rare and is only the second case to have ever been reported in the literature. Both our patients were successfully treated with antifungal therapy which included itraconazole monotherapy for case 1 and a combination of deoxycholate amphotericin B and itraconazole for case 2. We subsequently review the general aspects of sporotrichosis, specifically in renal transplant patients as described in the medical literature.

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