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Breakthrough zygomycosis on posaconazole prophylaxis after allogeneic stem cell transplantation

S Mousset1, G Bug, W J Heinz

  • 1Medizinische Klinik II, Klinikum der J.W. Goethe-Universität, Frankfurt am Main, Germany. sabine.mousset@kgu.de

Transplant Infectious Disease : an Official Journal of the Transplantation Society
|December 4, 2009
PubMed

Insights

Posaconazole prophylaxis can prevent invasive fungal infections in high-risk patients. However, breakthrough zygomycosis can still occur, as seen in a stem cell transplant patient despite adequate posaconazole levels.

Area of Science:

  • Mycology
  • Infectious Diseases
  • Hematology

Background:

  • Invasive fungal infections (IFIs) pose a significant threat to immunocompromised patients, particularly those undergoing allogeneic stem cell transplantation (SCT).
  • Posaconazole (POS) is a widely used antifungal agent for prophylaxis against IFIs in high-risk patient populations.
  • Graft-versus-host disease (GVHD) is a serious complication following allogeneic SCT, often necessitating immunosuppressive therapy, which further increases IFI risk.

Observation:

  • A patient with severe GVHD post-allogeneic SCT developed proven pneumonia caused by Rhizopus microsporus.
  • The patient had received 40 days of posaconazole prophylaxis, with documented fasting serum levels between 691-904 ng/mL.
  • Despite prompt initiation of combination therapy including liposomal amphotericin B and continued posaconazole, the patient succumbed to pulmonary hemorrhage.

Findings:

  • This case demonstrates a breakthrough invasive fungal infection (zygomycosis) due to Rhizopus microsporus despite effective posaconazole serum concentrations.
  • The patient's clinical course underscores the potential for treatment failure even with therapeutic drug levels and combination antifungal therapy.

Implications:

  • There is a critical need for heightened clinical vigilance regarding breakthrough zygomycosis in patients receiving posaconazole prophylaxis, even with confirmed therapeutic drug levels.
  • This case highlights potential limitations of current antifungal prophylaxis strategies and the complex management of IFIs in heavily immunocompromised patients.
  • Further research may be warranted to explore alternative or adjunctive strategies for preventing and treating invasive zygomycosis in high-risk SCT recipients.

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