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Kidney Week

Abstract: PO2465

Isavuconazole as Consolidation Therapy for Disseminated Histoplasmosis in a Kidney Transplant Recipient

Session Information

Category: Trainee Case Report

  • 1902 Transplantation: Clinical

Authors

  • Medani, Samar A., University of Wisconsin-Madison, Madison, Wisconsin, United States
  • Kessler, Michael, University of Wisconsin-Madison, Madison, Wisconsin, United States
  • Parajuli, Sandesh, University of Wisconsin-Madison, Madison, Wisconsin, United States
Introduction

The diagnosis of systemic fungal infection may be elusive and requires a high index of suspicion with prompt evaluation, directed laboratory and radiological work-up and if necessary, histological examination. To our knowledge, this is the first case report of isavuconazole use as consolidation therapy for disseminated fungal infection in a kidney transplant recipient.

Case Description

A 76-year-old female with polycystic kidney disease presented 8 years post kidney transplantation with a painful tongue ulcer, anorexia, weight loss, progressive anemia and severe de-conditioning. She was on maintenance mycophenolate, prednisone and tacrolimus. A midline fissure on the dorsal tongue surface (image 1- left). and two non tender nodular masses in the left forearm and right buttock were noted. A diagnosis of disseminated histoplasmosis was made by biopsy of the tongue ulcer, and cultures of blood, tongue tissue and forearm nodule aspirate .Blood and urine histoplasma antigens were positive. The patient was treated with amphotericin for two weeks before transitioning to itraconazole then to Isavuconazole due to QT prolongation. Mycophenolate was stopped. An outstanding clinical response with healing of the tongue ulcer (image 1 - right), shrinking of the subcutaneous lesions, and substantial functional progress to prior independence was seen within 3 months. Histoplasma urinary and plasma antigen levels declined to undetectable levels. Isavuconazole was continued for a year with no adverse side effects reported.

Discussion

Infections with Histoplasma capsulatum are largely asymptomatic but progressive disseminated mycosis can occur in the immunocompromised. There is no specified agent selectively approved for second line maintenance therapy when itraconazole is not tolerated or is ineffective. Limited experience has been reported with other azoles, and even less so with isavuconazole. This case demonstrates an excellent outcome of treating disseminated histoplasmosis with isavuconazole in a kidney transplant recipient.

Ulcerated median sulcus of the tongue, before (left) and 8 months after (right) starting antifungal therapy