RESUMEN
A 56-year-old male who was 12 months status post liver transplant presented with a 2-month history of painful, erythematous nodules over the right knee. Several biopsies yielded a mold initially phenotypically identified as a Penicillium species, but molecular sequence analysis ultimately determined the identity as Paecilomyces lilacinus. Several courses of oral voriconazole were required for resolution of the infection. A review of the literature revealed that Paecilomyces species are an infrequent cause of disease in transplant patients, with skin and soft tissue infections being the most common presentation. It is important to accurately identify these infections, and polymerase chain reaction assay using universal fungal primers offers a rapid and precise diagnostic approach. Treatment of Paecilomyces infections may require multiple courses of antifungal therapy, often with surgical debridement. We suggest that voriconazole may be a useful treatment alternative to the more traditional therapy with amphotericin B-based agents.
Asunto(s)
Antifúngicos/uso terapéutico , Trasplante de Hígado , Micosis/diagnóstico , Micosis/tratamiento farmacológico , Paecilomyces/patogenicidad , Pirimidinas/uso terapéutico , Triazoles/uso terapéutico , Humanos , Cooperación Internacional , Trasplante de Hígado/efectos adversos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , VoriconazolRESUMEN
Histoplasma capsulatum sporadically causes severe infections in solid organ transplant (SOT) patients in the Midwest, but it has been an unusual infection among those patients followed at the University of Nebraska Medical Center (UNMC), located at the western edge of the 'histo belt.' Nine SOT patients with histoplasmosis are described (6 renal or renal-pancreas and 3 liver recipients) who developed severe histoplasmosis over a recent 2.5-year period at UNMC. Symptoms started a median of 11 months (range, 1.2-90 months) after organ transplant and consisted primarily of fever, cough, shortness of breath, and malaise or fatigue present for approximately 30 days prior to medical evaluation. All patients had an abnormal chest radiograph and/or computed tomographic scan. Tacrolimus was the main immunosuppressant in all 9 patients, along with prednisone or mycophenolate. Dacluzimab or thymoglobulin had been given around the time of transplant in 6 of 9. None was treated for an episode of acute rejection within 2 months before onset of histoplasmosis, although 2 were on high-dose immunosuppression after recent transplants. Diagnosis was made by culture in 8 of the 9 patients, with positive serum and urine histoplasma antigen tests in all 9 cases. From 1997 to 2001, during a period of relative quiescence of the disease in the general population, the rate of clinical histoplasmosis among SOT patients at UNMC was estimated at 0.11%, whereas during 2002 through the first half of 2004, the rate rose 17-fold to 1.9%. Histoplasmosis can present as a prolonged febrile illness with subacute pulmonary symptoms in a cohort of SOT patients, despite the absence of a regional outbreak.