Immunosuppressants and voriconazole
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Immunosuppressants and voriconazole Various toxicities and drug interaction: case report
A 46-year-old man developed cytomegalovirus enteritis during treatment with methylprednisolone, basiliximab and antithymocyte-globulin, and developed acute cholestatic hepatitis during treatment with voriconazole. Additionally, he had elevated tacrolimus level following concomitant therapy with voriconazole and tacrolimus [routes and duration of treatments to reactions onsets not stated; not all dosages stated]. The man with a history of familial adenomatous rectocolic polyposis and panproctocolectomy, had undergone an intestinal transplantation in November 2011. He received induction immunosuppressant therapy with alemtuzumab and bolus methylprednisolone upon graft reperfusion. Following the transplantation, he received tacrolimus as maintenance therapy. In subsequent days, he developed multi-drug resistant surgical mesh Pseudomonas aeruginosa infection [aetiology not stated], which required removal of the surgical mesh and surgical closure of the wound. Between June-September 2015, he received combination therapy with sofosbuvir, ledipasvir and ribavirin for chronic active hepatitis secondary to hepatitis C virus (HCV). In June 2016, he was diagnosed with grade 3 late cellular rejections. Hence, he started receiving bolus methylprednisolone 1 gram/day for 3 days, basiliximab and antithymocyte-globulin [thymoglobulin]. Subsequently, he developed developed graft enteritis due cytomegalovirus (CMV) infection associated with methylprednisolone, basiliximab and antithymocyte-globulin. The man received treatment with different cycles of valganciclovir and foscarnet. His CMV infection was refractory to treatment with valganciclovir and foscarnet (lack of efficacy). Subsequently, his antiviral therapy was switched to leflunomide, as he developed unspecified severe side effects with antiviral therapy. His cytomegalovirus (CMV) infection recovered following leflunomide therapy. In July 2017, he presented with severe headache and right eye (RE) proptosis. Further ophthalmology examination revealed palpebral ptosis and proptosis of the RE of up to 3mm, accompanied by pupillary anisocoria with reactive mydriasis and ophthalmoplegia. Subsequent computed tomography of the skull showed a soft tissue lesion in the base of the right orbit. A cranial magnetic resonance image showed multiple annular and bilateral nodules in the brain and cerebellum compatible with fungal abscesses and focal and hypocapillary lesions extending from the right sphenoid sinus towards the orbital apex and the top of the right cavernous sinus. Then, chest x-ray and computed tomography of the thorax showed multiple cavitated bilateral pulmonary lesions. Due to the high suspicion of invasive fungal infection (IFL), he started receiving amphotericin-B-liposomal [liposomal amphotericin B] and voriconazole 400 mg/12h for the first 24h, followed by 200 mg/12h. The biopsies of the lesion showed fungal structures of Aspergillus fumigate. Based on the biopsy result, inv
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