Successful treatment of Candida spp. encephalitis occurring under Caspofungin treatment after allogeneic stem cell transplantation

Abstract

Dear Editor, Caspofungin belongs to standard drugs for empirical antifungal therapy (A1 recommendation) [1]. Breakthrough fungal infections are rare complications under treatment of neutropenic fever with Caspofungin [2]. However, emergence of candidiasis under treatment with Caspofungin was reported in poorly penetrated organs [3]. Drug concentrations of Caspofungin are sub-optimal in brain tissue [4]. Cerebral fungal infections are rare but life-threatening complications after allogeneic stem cell transplantation. Early diagnosis and critical monitoring of response to the chosen antifungal agents is critical for successful treatment. We report about the diagnosis and treatment of a 69-year-old female patient who underwent allogeneic peripheral blood stem cell transplant from a related donor against AML M2 developed out of MDS. Conditioning comprised of TBI 2Gy, Fludarabin 120 mg/m, ATG 40 mg/kg, Cyclophosphamid 120 mg/kg. Immunosuppression was accomplished by Ciclosporin A and Mycophenolat Mofetil. The patient did not completely engraft. Six months after transplantation, the patient developed pneumonia. As she did not improve under treatment with piperacillin or combactam and teicoplanin, we added caspofungin after 72 h. Hereunder, she improved tremendously. After 4 weeks, she developed ataxia and dysarthria. The cranial magnetic resonance imaging (MRI) showed two lesions most likely to be of infectious origin in the left parietal lobe and in the cerebellum (Fig. 1). Candida polymerase chain reaction of the liquor was positive. A second liquor puncture confirmed this result. Treatment was initiated with liposomal Amphothericin B 3 mg/d/kg intravenous and Voriconazol 200 mg twice a day per os. Within 2 weeks, all clinical symptoms resolved andwithin 4 weeks, the control MRI showed remission. Treatment with Voriconazol was continued for 6 weeks. In part, Candida breakthrough infections may be due to the changing scope of strains [5]. However, to our knowledge, only a few cases of candida breakthrough infections under Caspofungin are reported [3–9]. Krogh-Madson et al. isolated Caspofungin resistant C. glabrata from a critically ill liver transplant patient [6]. In another case C. parapsilosis infection emerged under co-administration of phenytoin maybe leading to decreased Caspofungin concentrations [6]. Mougdal et al. showed by molecular-genetic studies that one initial susceptible Candida glabrata strain acquired resistance to Caspofungin under therapy [9]. As penetration of caspofungin in Ann Hematol (2009) 88:93–94 DOI 10.1007/s00277-008-0551-3