Case Study: Posaconazole Treatment of Disseminated Phaeohyphomycosis Due toExophiala spinifera

Abstract

A 41-year-old woman with no known immunosuppression experienced a 12-year period of a relapsing phaeohyphomycosis. Despite administration of multiple courses of therapy with standard antifungals, sustained clinical remission was not achieved. A partial response was seen initially with the combination of itraconazole and flucytosine therapy, but the patient did not respond to subsequent treatment. During the patient's pregnancy, the mycosis became disseminated, with lymphadenopathy and fever, and was considered life threatening. Despite receipt of parenteral amphotericin B therapy, the patient did not show a clinical response. After premature delivery by cesarean section, treatment with oral posaconazole suspension (800 mg/day) was started. The patient's condition improved within 1 week after initiating treatment; therapy was continued for 13 months. During posaconazole treatment, the patient showed a complete clinical response, with negative results of fungal cultures.

Spectrum of Clinically RelevantExophialaSpecies in the United States

“…Strains of E. spinifera were mainly involved in cutaneous and subcutaneous mycoses. Outside the United States several cases of disseminated infection caused by this species have been reported (5,31,36,40) in individuals without known immune disorder. The reason for the absence of systemic disease in the United States is unknown.…”

“…The clinical outcome in deep infection, however, is dismal (6,7,29,23,26,33,35). Improvement may be expected, since posaconazole has shown striking effects in treating a case of disseminated infection (31).…”

Rare and Emerging Opportunistic Fungal Pathogens: Concern for Resistance beyondCandida albicansandAspergillus fumigatus

“…These organisms are characterized by the presence of a pale brown to dark melanin-like pigment in the cell wall. The dematiaceous fungi may cause a variety of cutaneous and subcutaneous infections in immunocompetent individuals and invasive or disseminated infections in both immunocompetent and immunocompromised patients (69,90,97).…”

“…Despite these efforts, phaeohyphomycosis does not respond well to therapy and relapses are common (69,90).…”

“…Posaconazole has successfully been used to treat disseminated infections due to Exophiala spinifera (69). In those patients with brain abscesses, complete excision of the lesion has been associated with improved survival (90).…”