Successful treatment of black-grain mycetoma with voriconazole

Fungal mycetoma (or eumycetoma) are endemic diseases in tropical areas that have economic effects because of their chronic and disabling evolution. Classic treatments include surgery and antifungal drugs, but these have multiple side effects. We report a case of black-grain fungal mycetoma successfully treated with voriconazole without side effects. The duration of the treatment remains unclear, but must be prolonged because of the frequency of relapses.     

Successful treatment of Candida glabrata myocarditis with voriconazole

A 30-y-old man with Crohn's disease developed fungemia with Candida albicans. Subsequently, during therapy with fluconazole, Candida glabrata was repeatedly isolated from his blood. Myocardial abscesses were detected in the papillary muscles and interventricular septum. The infection was cured with amphotericin B lipid complex and 5-flucytosine, followed by voriconazole for 18 months.     

Successful treatment of Paecilomyces lilacinus endophthalmitis with voriconazole

Paecilomyces lilacinus is a rare cause of endophthalmitis and there are few reports of it in the literature. Herein we report a patient with P. lilacinus endophthalmitis who was treated with the new triazole, voriconazole, for 4 months, with a good clinical evolution. This treatment appears to be a valuable new therapeutic option but requires further clinical confirmation.     

Successful treatment with voriconazole for disseminated cutaneous and visceral infection by Fusarium solani in a patient with acute myeloid leukemia

We report the successful treatment of a disseminated Fusarium infection with skin manifestations in a severely neutropenic patient. A 51-year-old man with acute myeloblastic leukemia (M4) underwent two courses of remission induction therapy with cytarabine and daunorubicin. Despite prophylactic treatment with tosufloxacin and micafungin, the patient developed a febrile scrotal ulcer. Eight days later, we noted the appearance of painful and diffuse cutaneous nodules and a plain chest X-ray disclosed multiple nodular lesions. Microbiological examination of the scrotal ulcer revealed infection by Fusarium solani, which was also confirmed by both histological and microbiological examination of the skin nodules. Although the patient was treated with amphotericin B (AMPH-B), the clinical symptoms worsened. After AMPH-B was replaced with voriconazole (VRCZ), the patient's symptoms and chest radiographic findings dramatically improved. Thus, VRCZ might be an alternative therapy for patients with neutropenia who have fusariosis that is refractory or unresponsive to AMPH-B.     

Successful treatment of stasis dermatitis with topical tacrolimus

Stasis dermatitis is a common dermatologic disorder as a consequence of impaired venous drainage and often accompanied by chronic leg ulcers. Until today the standard in acute therapy represents the topical administration of highly potent corticosteroids and if possible a consequent long-term compression therapy. The macrolide tacrolimus represents a new selective inflammatory cytokine release inhibitor by binding to macrophilin-12 and inhibiting calcineurin. Beside the resulting anti-inflammation and immunosuppression an antipruritic effect have been discussed as further clinical benefits of tacrolimus. Here we report for the first time about a 81-year old patient suffering from an ulcus cruris mixtum and stasis dermatitis treated with topical 0.1% tacrolimus ointment twice daily for 5 days. Until now tacrolimus is available for topical treatment as a fatty ointment only. Although we would have preferred a more hydrophilic base for treatment of acute stasis dermatitis we achieved complete healing. As this is only a case report about one single patient further clinical investigations are needed to confirm this observation in more individuals with stasis dermatitis.     

Successful treatment of Candida parapsilosis mural endocarditis with combined caspofungin and voriconazole

Background  

Fungal mural endocarditis is a rare entity in which the antemortem diagnosis is seldom made. Seven cases of mural endocarditis caused by Candida spp. have been collected from literature and six of these patients died after treatment with amphotericin B.     

Successful treatment of disseminated Fusariosis after allogeneic hematopoietic stem cell transplantation with the combination of voriconazole and liposomal amphotericin B

Fusarium is an opportunistic fungal pathogen which is emerging as a significant cause of morbidity and mortality in the immunocompromised host [Fleming RV, Walsh TJ, Anaissie EJ. Emerging and less common fungal pathogens. Infect Dis Clin North Am 2002;16:915–34]. This disease can be localized, focally invasive or disseminated, when two or more noncontiguous sites are involved. Therapeutic options are scarce and mortality reaches 80–90% in patients subjected to allogeneic hematopoietic stem cell transplant (allo-SCT) [Nucci M, Marr KA, Queiroz-Telles F, Martins CA, Trabasso P, Costa S, et al. Fusarium infection in hematopoietic stem cell transplant recipient. Clin Infect Dis 2004;1237–42]. We report a case of disseminated Fusariosis in a severe immunocompromised patient after allo-SCT that responded to treatment with the early combination of intravenous voriconazole and liposomal amphotericin B.     

Successful treatment of systemic Geotrichum capitatum infection by liposomal amphotericin-B, itraconazole, and voriconazole in a Japanese man

Severe systemic Geotrichum capitatum (G. capitatum) infection is rare, especially in Japan. G. capitatum infection has been reported mainly in immunocompromised patients and the prognosis is poor with a mortality rate of approximately 50-75%. Here, we report a Japanese case of systemic G. capitatum infection in a severe neutropenic patient who was receiving chemotherapy for acute myelogeneous leukemia with multilineage dysplasia. G. capitatum was isolated from blood cultures, and also formed multiple nodular lesions in lung fields. The infection was successfully cured with a combination of amphotericin B, itraconazole, and voriconazole.     

Successful treatment of disseminated Fusarium infection after autologous bone marrow transplantation for acute myeloid leukemia

Disseminated Fusarium is a rare but life-threatening infection of severely immunocompromised patients. A fatal outcome has been described in all reported cases of Fusarium infection occurring after bone marrow transplantation. We describe a patient who developed disseminated Fusarium infection with a secondary fungal endophthalmitis after an autologous bone marrow transplant for acute myeloid leukemia. This infection was successfully eradicated after neutrophil recovery by prolonged systemic administration of amphotericin B as well as aggressive local therapy including enucleation of the affected eye. The patient remains free of both leukemia and fungal disease more than 4 years after transplant.     

Successful treatment by voriconazole for pulmonary aspergilloma of elderly patient]

A 75-year-old man was admitted with bloody sputum. His chest radiogram and CT revealed a fungus ball within a cavity lesion of the right upper lung field. Aspergillus fumigatus was cultured from bronchoalveolar lavage fluid. He was treated with itraconazole (ITCZ) and micafungin (MCFG), but his fungus ball increased. One year after initiating voriconazole (VRCZ) therapy. After 1 year, the fungus ball had significantly reduced, with no significant adverse events. This case suggests that administration of VRCZ can be recommended for pulmonary aspergilloma of responding poorly to other antifungal agents.     

Successful treatment of disseminated Fusarium infection in an infant with leukemia

Disseminated Fusarium infection in an immunocompromised host is intractable and results in high mortality. We provide the first full case report on successful treatment of a disseminated Fusarium infection in an infant. The 6-month-old infant, whose family raised livestock, had infantile leukemia. During the neutropenic period after intensive chemotherapy, vomiting, diarrhea, fever, subcutaneous nodes, and coughing appeared. Pneumonia was diagnosed, and Fusarium moniliforme was isolated from blood culture. A central venous catheter was removed. Granulocyte colony-stimulating factor (G-CSF) and amphotericin B (AMPH-B) (total dose, 65 mg/kg) were administered continuously for 8 weeks. The infection was resolved according to improvement of clinical and laboratory findings, and intensive chemotherapy was restarted for the leukemia. Cord blood stem cell transplantation from an unrelated donor was performed. The Fusarium infection did not recur, but after transplantation, leukemia relapsed. Treatment of neutrophils using G-CSF, AMPH-B, and local treatment induced resolution of the disseminated Fusarium infection in this immunocompromised host with malignancy. We suggest caution for patients living in an environment conducive to the development of Fusarium infection because of the particular risk of infection.     

Successful treatment of gangrene in systemic necrotizing vasculitis with iloprost

Systemic necrotizing vasculitis is uncommon in children and may be rarely associated with gangrene. We describe a 3-yr-old girl with parvovirus B19-induced necrotizing vasculitis whose digital gangrene was successfully treated with iloprost, a prostacyclin analogue.      

Successful treatment with leflunomide of arthritis in systemic sclerosis patients

SIR, Systemic sclerosis (SSc) is a connective tissue diseaseclinically characterized by different degrees of skin fibrosisand visceral organ involvement [1]. Joint involvement with severesynovitis during SSc is relatively uncommon. About 11% of SScpatients present with arthritis at disease onset [2], usuallycharacterized by mono-oligoarthritis, responsive to     

Successful treatment of pediatric systemic polyarteritis nodosa with cholestatic hepatitis

Polyarteritis nodosa (PAN) is a rare vasculitis in children. We report a case of 5-year-old boy with systemic PAN and cholestatic hepatitis. He had fever, abdominal pain, and gastrointestinal bleeding. Angiography revealed multiple microaneurysms in the renal, hepatic, and superior mesenteric arteries. Clinical manifestations improved slowly after immunosuppressive therapy, but liver enzyme and bilirubin levels elevated gradually. Liver biopsy findings revealed marked centrizonal canalicular cholestasis, bile duct damage, and intact hepatocyte, but there was no evidence of viral hepatitis or vasculitis. Levels of liver enzymes and bilirubin improved after two cycles of cyclophosphamide therapy. We thought that the possible etiology of elevated liver enzyme and bilirubin levels might be a manifestation of PAN.     

Successful treatment of refractory systemic lupus erythematosus with intravenous immunoglobulins

Two cases of refractory systemic lupus erythematosus (SLE) were successfully treated with intravenous immunoglobulins (IVIg). In Case 1, the immediate recovery from severe pancytopenia and the improvement of proteinuria were observed, following IVIg therapy in high doses (450 mg/kg) for 5 consecutive days. In Case 2, 3 courses of IVIg therapy (100 mg/kg) for 6 to 8 days resulted in a significant reduction of massive proteinuria. In both cases, the improvement of immunological variables was also seen.     

Successful long-term treatment of systemic lupus erythematosus with rituximab maintenance therapy

Systemic lupus erythematosus (SLE) is a chronic, inflammatory autoimmune disease that may involve multiple organ systems. Treatment consists of immunosuppression, cytotoxic treatment, plasmapheresis and immunoglobuline therapy. Treatment of patients refractory to standard treatment approaches is difficult and results are poor. We describe a 39-year old patient with SLE suffering from grand mal epilepsy due to cerebral vasculopathy with positive lupus anticoagulant, who was refractory to standard treatment modalities. The patient was treated with the anti-CD20 monoclonal antibody rituximab (375 mg/m2 x 4, repeated at weekly intervals). Rituximab applications were delivered in October 2000, March 2001 and October 2001. Since March 2002 she has received maintenance therapy with rituximab 375 mg/m2 every three months. A second female with refractory SLE was treated successfully in April 2002 and receives maintenance therapy every three months. Both patients responded well to rituximab therapy. The first patient showed a major improvement of her clinical condition, and 30 months after the beginning of the rituximab therapy she is free of any symptoms. Inflammation parameters, ANA and lupus anticoagulant declined significantly after the treatment. The clinical condition of the second patient improved dramatically, all inflammation parameters normalized and her circulating immunocomplexes disappeared. In conclusion, rituximab maintenance treatment may be a new effective therapy in SLE.     

Successful treatment of fulminant pulmonary hemorrhage associated with systemic lupus erythematosus

We report a patient with systemic lupus erythematosus (SLE) who developed fulminant pulmonary hemorrhage. This patient also showed liver dysfunction, bicytopenia and hyperferritinemia, with an increase in serum levels of interleukin (IL)-1, IL-6 and tumor necrosis factor- (TNF-) at the onset of pulmonary symptoms, probably indicating an associated hemophagocytic syndrome. Despite an acute progressive course temporarily requiring mechanical ventilation the patient was successfully treated with continuous drip infusion of tacrolimus, plasmapheresis and intravenous high-dose immunoglobulin and corticosteroid. In this patient increased inflammatory cytokines ascribable to activation of macrophages and/or helper T cells were considered to play an important role in the pathogenesis of the pulmonary hemorrhage. Because this complication is frequently fatal in SLE, intensive therapy, including immunosuppressants and plasmapheresis, should be actively considered as early as possible after onset.Abbreviations HPS Hemophagocytic syndrome - SLE Systemic lupus erythematosus - TNF Tumor necrosis factor