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Candida glabrata infection and acquired caspofungin resistance: case report A 47-year-old man developed Candida glabrata (C. glabrata) infection during immunosuppressive treatment with mycophenolate mofetil, prednisolone, methylprednisolone, mycophenolate, ciclosporin and budesonide. Additionally, he also acquired drug resistance for caspofungin, while being treated for Candida glabrata infection [not all dosages and routes stated]. The man was admitted due to diarrhoea secondary to a suspected acute graft-versus-host disease (GVHD) of GI tract. His medical history was significant for chronic lymphocytic leukaemia requiring allogeneic haematopoietic stem cell transplantation and was allergic to ramipril and prochlorperazine. Also, he had a history of depression, smoking, skin GVHD and alcohol misuse. On admission, his immunosuppressive regimen consisted of oral mycophenolate mofetil 1g twice a day, oral prednisolone 25 mg/day and mycophenolate. Other regular medications included cotrimoxazole [trimethoprim/sulfamethoxazole], valaciclovir, posaconazole, pantoprazole and paroxetine. Laboratory tests on admission revealed WBC 4.3 × 109/L, platelet count 183 × 109/L, neutrophil count 1.7 × 109/L and Hb level 111 g/L. He was treated with IV methylprednisolone 20 mg/day for acute GVHD of GI tract, which was adjusted to 2 mg/kg on day 4. Total parenteral nutrition was also initiated. His mycophenolate therapy was stopped as he had significant bowel output, and IV ciclosporin infusion was initiated. As he had a history of nephrotoxicity with ciclosporin, initially ciclosporin was started at a lower dose of 2 mg/kg/day. However, the GVHD showed no improvement by day 16. Hence, IV mycophenolate was re-initiated at an increased dose of 1g three times a day. Oral budesonide 3mg three times a day was also started on day 31. Both peripheral and central blood cultures revealed yeasts on day 38, which was identified as C. glabrata. His posaconazole therapy was stopped on day 40. The man was treated with IV caspofungin at a loading dose of 70mg, followed by 50 mg/day for 16 days. His central and peripheral lines were replaced. On day 41, the blood cultures were found to be negative. Posaconazole was initiated for fungal prophylaxis following completion of caspofungin course. He was trialled with oral ruxolitinib 10mg twice a day on day 44 for GVHD, and mycophenolate therapy was stopped as per trial requirements. His ciclosporin therapy was stopped due to haemolysis [aetiology unspecified] on day 51, and mycophenolate was re-initiated. He developed neutropenia on day 61. Blood culture again showed growth of C. glabrata on day 67. He was re-initiated on caspofungin on day 69 with the same dosing schedule as prior, and posaconazole was stopped. His blood cultured after 4 days were still positive for C. glabrata. Susceptibility testing revealed that the species had acquired resistant to echinocandins, indicative of acquired caspofungin resistance. On day 72, caspofungin was ceased, and amphotericin-B liposomal was initiated. His b