Verruconus gallopava CNS Infection in a Heart-Kidney Transplant Recipient

Abstract

Introduction Dematiaceous fungal infections are uncommon and have diverse clinical manifestations. CNS involvement is among the rarest manifestations and typically presents as a brain abscess. Verruconus gallopava has been isolated in cases and appears to be associated with immunocompromised hosts, particularly the post-transplant population. There is no standardized treatment regimen for dematiaceous fungal CNS infections. Recommendations are largely based on in-vitro data and studies derived from case reports. Anti-fungal agents and complete excision of brain abscesses portends the best survival, although prognosis remains poor, with overall mortality >70%. Case Report Ms. H was a 50 yo F with a PMH of NICM c/b cardiorenal syndrome s/p combined heart-kidney transplant (on mycophenolate, tacrolimus and prednisone) who was brought to the ED 4 months post-transplant with altered mental status (AMS). 1 week prior to presentation, Ms. H developed intermittent headaches and progressive AMS. Vital signs WNL. Physical exam significant only for confusion and lethargy. Labs unremarkable. MRI brain revealed a L frontal lobe abscess w/ surrounding vasogenic edema and L-to-R midline shift. Ms. H underwent emergent L frontal craniectomy for abscess D&C. Empiric antibiotics were started and mycophenolate held. She worsened clinically and radiographically, compelling a L frontal lobectomy. Initial cultures grew mold, so liposomal amphotericin B (L-AmB) was added and antibiotics eventually discontinued. CT chest revealed a fungal abscess in the RLL, which was determined to be the primary source of infection. Cultures eventually speciated Verruconus gallopava, and voriconazole was added. Susceptibilities showed MICs of 2mcg/ml for AmB and 0.50 mcg/ml for voriconazole. However, she continued to decline, and voriconazole was switched to posaconazole (MIC of 0.25mcg/ml). Ms. H gradually improved and, after an 8-month hospital course, was discharged in stable condition on lifelong posaconazole monotherapy. At 1-year post-transplant f/u, L/RHC/biopsy showed hemodynamics WNL, CAV0, and no evidence of acute cellular rejection. Summary High clinical suspicion for dematiaceous fungi in brain abscesses is needed as these are rarely seen in practice. For Ms. H, a combination of posaconazole, L-AmB, and surgical intervention treated her life-threatening V. gallopava CNS infection.