Posaconazole
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Fatal breakthrough Rhizopus infection (first report) on prophylaxis: case report A 55-year-old man receiving posaconazole for prophylaxis against invasive pulmonary aspergillosis following a stem cell transplant developed a breakthrough Rhizopus infection. He subsequently died. The man was receiving high-dose steroids, ciclosporin and voriconazole. Eight weeks after switching from voriconazole to posaconazole 400mg twice daily (and 8.5 months posttransplantation), he presented with a 1–week history of fever (38.2°C), asthenia and left orbital pain, peri-orbital oedema, nasal obstruction and a central palatine necrotic lesion. A head CT showed rhino-orbital and sinusal involvement consistent with rhino-sinusal zygomycosis. Three days later, biopsy samples confirmed invasive zygomycosis, and cultures grew Rhizopus oryzae. The man was initiated on amphotericin B liposomal, imipenem, vancomycin and amikacin. Three days later, the infection rapidly worsened, with extension of the necrotic area. The antibacterials were ceased and the dose of amphotericin B liposomal was increased. Ciclosporin was discontinued and the steroids were tapered. He also received granulocyte-colony-stimulating factors due to moderate neutropenia. The palatine necrosis spread, with involvement of the left peri-orbital subcutaneous tissue, and he experienced digestive bleeding and two generalised seizures. His neurological status progressively worsened, and he died 20 days after being admitted. No autopsy was performed. Author comment: "Although posaconazole has in vitro activity against Zygomycetes spp, and has been used as salvage therapy for patients with zygomycosis, it might not be active against all zygomycetes species in vivo." Schlemmer F, et al. Breakthrough Rhizopus infection on posaconazole prophylaxis following allogeneic stem cell transplantation. Bone Marrow Transplantation 42: 801124532 551-552, No. 8, Oct 2008 - France
» Editorial comment: A search of AdisBase, Medline and Embase did not reveal any previous case reports of lack of efficacy associated with posaconazole. The WHO Adverse Drug Reactions database contained five reports of posaconazole being ineffective.
0114-9954/10/1228-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved
Reactions 15 Nov 2008 No. 1228
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