Successful treatment of oral invasive aspergillosis with voriconazole

Abstract

Background. Aspergillosis is a life-threatening complication of hematopoietic stem cell transplantation (HSCT). Compared to amphothericin B (AMB), fluconazole is much less effective for the treatment of aspergillosis. Voriconazole is a new triazole antifungal agent. Recent observation demonstrated the potential for emergence of resistance among fungal pathogens while receiving voriconazole therapy. Case report. A 34-year-old man was evaluated prior to HSCT in order to eliminate oral foci of infection. Clinical findings suggestive of necrosis in the maxilla were noted. Aggressive debridement and extraction of the involved teeth were performed under local anesthesia. Based on histopathologic and microbiologic findings, a diagnosis of mixed Aspergillus flavus and Candida krusei infection was made. Treatment was initiated with high-dose IV AMB (1.5mg/kg/day) and topical AMB in parallel to the pre-HSCT cytotoxic conditioning regimen. Local clinical deterioration with extension of the infection to the maxillary sinus on CT and repeated microbiologic evaluation indicated poor response to the treatment. Voriconazole was added (200 mg bid). A gradual improvement was observed in parallel to an engraftment of the hematopoietic stem cells. The maxillary lesion healed leaving an extensive alveolar defect. The voriconazole treatment was well tolerated. Conclusion. To the best of our knowledge, this is the first documentation of a successful treatment of oral invasive aspergillosis with voriconazole. This new drug may be an essential aid in cases of fungal infections.