Treatment of Refractory Cerebral Aspergillosis in a Liver Transplant Recipient With Voriconazole: Case Report and Review of the Literature

Abstract

Extension of invasive aspergillosis to the central nervous system is associated with high mortality, in part because of poor central nervous system penetration of antifungal drugs. Voriconazole yields fungicidal drug concentrations within the central nervous system, but use of this drug is limited in liver transplant recipients because of hepatotoxicity and drug interactions. We reviewed medical records and antifungal treatment for all liver transplant recipients from 2007 to 2009 who had cerebral aspergillosis (Proven [2]; Probable [1]; Possible [1]) at week 3, 4, 6, and 12 after transplant. A 33-year-old white man underwent orthotopic liver transplant for acute liver failure that was caused by acetaminophen overdosage. Risk factors for fungal infection included major blood loss (8 L), prolonged surgery (9 h), and emergency revision transplant that was done because of nonfunctioning of the primary transplant at 48 hours. He developed postoperative aspergillus pneumonia and invasive aspergillosis of the kidneys, brain, and eye. Treatment with voriconazole and amphotericin B was successful, with moderate residual renal impairment. Voriconazole was effective and safe in the treatment of cerebral aspergillosis in this liver transplant recipient.