INTRODUCTION: αInvasive fungal infections represent a major complication of organ transplantation. Zygomycoses have a devastating clinical course and portend a poor prognosis with high mortality. Prior case reports and case series have demonstrated a favorable outcome following a combination of medical and surgical treatment for infections with rhizopus species. Infection with Absidia corymbifera in transplant recipients however, has been associated with a fatal outcome. We describe a case of Absidia corymbifera brain abscess in a lung transplant recipient who was successfully treated with a combination of medical and surgical treatment.
CASE PRESENTATION: A 21-year-old Caucasian male three months status post bilateral lung transplantation for end stage lung disease secondary to cystic fibrosis presented with right-sided temporal headache with retro-orbital pain, nausea, and photophobia. Immunosuppression on admission included tacrolimus, prednisone, and azothioprine. He was afebrile, vital signs were normal, and pulse oximetry was 100% on room air. Exam revealed right eye photophobia with blepharospasm, no meningismus or focal neurological deficit. MRI of brain revealed a 2.5cm right parietal ring enhancing cystic lesion with leftward midline shift and pansinusitis (Figure 1). Sinus aspiration and culture revealed Pseudomonas aeruginosa. Therapy was initiated with intravenous piperacillin/tazobactam, ciprofloxacin, oral voriconazole, and dexamethasone. Four days later, his headaches recurred. Neurologic exam was non focal and MRI of the brain did not reveal any significant change. Brain biopsy and aspiration of the lesion revealed “septate” hyphae suggestive of Aspergillus, however zygomycetes could not be ruled out and lipid complex amphotericin was initiated. His headaches persisted and he developed mental status changes two weeks into therapy with amphotericin. Repeat MRI of the brain revealed progression and he subsequently was taken to the operating room for a right parieto-occipital craniotomy with drainage of abscess and occipital lobectomy. Surgical specimens revealed fungal elements consistent with Absidia corymbifera (Figure 2). He was subsequently treated with a 10 week course of liposomal amphotericin after which he had fully recovered with mild residual deficits.
DISCUSSIONS: Invasive fungal infections represent a major complication of organ transplantation. The incidence of non-Aspergillus mold infections in transplant recipients has increased over the past decade with a reported incidence of 1-9%, 60 days after transplantation and the mortality has remained high. Risk factors include high dose corticosteroids, multiple or recent rejection episodes, hyperglycemia, poor transplant function, leucopenia, and older age.Zygomycoses usually have a devastating clinical course with a 56% overall mortality. Successful therapy involves co-ordinated combination of surgical removal of devitalized tissue and intravenous amphotericin B 1. Absidia corymbifera infections have been reported to involve cutaneous, rhino-cerebral, pulmonary and gastro-intestinal sites and are known to be voriconazole resistant. It is an uncommon cause of brain abscess. Although several cases of absidiomycosis have been described in literature, a vast majority of them have been fatal except for “cure” reported with pulmonary infection in a non-immunocompromised host 2. Outcome with rhino-cerebral infection has invariably been fatal. This is the first case reported of Absidia corymbifera brain abscess in a lung transplant host which was successfully treated with a combination of medical and surgical therapy.
CONCLUSION: There should be a high level of suspicion for potential zygomyces infections in immunocompromised hosts. Early diagnosis and surgical debridement along with amphotericin are requisite for a successful outcome.
DISCLOSURE: Nehal Bhatt, None.