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

Discussion

Opportunistic infections are common in organ transplant patients, where fungal infections comprise 6% of all infections. Candida species, Aspergillus species and Cryptococcus neoformans are most frequently isolated.[9] Sporotrichosis is rare in transplant patients, and in these patients, it occurs mostly in renal transplant recipients, although Bahr et al.[10] reported sporotrichosis in a lung transplant patient and da Silva et al.[11] recently reported the first case of sporotrichosis in a liver transplant recipient. After a thorough search of the relevant literature our case (case 2) is only the second reported case of meningeal sporotrichosis in a renal transplant recipient, the first case was reported in 1987 by Gullberg et al..[4] Our patient (case 2) differs from the one reported[4] by the way he presented clinically with features suggestive of tuberculous meningitis and no stigmata of cutaneous or lymphocutaneous sporotrichosis; thus making the diagnosis a challenge. Patients with meningeal involvement present with various symptoms, including: fever, headache, neck stiffness, vomiting, seizures, and altered mentation.[1] Important differential diagnoses include cryptococcal meningitis and tuberculous meningitis.[12] Investigations include a LP which is usually lymphocyte predominant with low CSF glucose and high protein levels. Tissue/CSF fungal culture is the gold standard and most sensitive method but may take longer to yield results while fungal PCR and sequencing can also be utilized to more rapidly identify SS.[3] Treatment is notoriously difficult given the paucity of clinical trials and the overlapping nature of the clinical features and laboratory investigations of this rare disease with more common aetiologies. Clinical practice guidelines of the Infectious Disease Society of America[13] recommend using itraconazole for cutaneous/lymphocutaneous involvement at 200 mg once daily for up to 2–4 weeks after the lesions have resolved – terbinafine 500 mg twice daily can be used as an alternative. Meningeal involvement is treated more aggressively with liposomal amphotericin B for at least 4 to 6 weeks at a dose of 3–5 mg/kg, followed by itraconazole 200 mg twice daily for at least 1 year. Deoxycholate (conventional) amphotericin B can be used as an alternative. Itraconazole prophylaxis at 200 mg once daily is to be continued life-long or until immunosuppression has been withdrawn. Calcineurin inhibitor dosage should be lowered by 33–66% to maintain the recommended therapeutic levels.[14] The significant inhibition of the Cytochrome P450 3A4 by the azoles leads to decreased metabolism with subsequent increased therapeutic levels of CNI's leading to potential CNI toxicity. At our unit we reduce the total daily CNI dose by 66% following the first 24 hours of azole therapy, and subsequently adjust the dose according to the required through levels.

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