VORICONAZOLE-ASSOCIATED MUCOSAL ULCERATION AFTER LUNG TRANSPLANT

Abstract

TYPE: Case Report TOPIC: Transplantation INTRODUCTION: Colonization and isolation of Aspergillus from bronchial specimens predisposes lung transplant (LTx) recipients to airway anastomotic complications and allograft rejection. Post-LTx antifungal prophylaxis with voriconazole has been associated with cutaneous malignancies. We report a case of voriconazole-associated mucosal ulceration in an LTx recipient that improved upon drug discontinuation. CASE PRESENTATION: A 56-year-old LTx recipient (November 2020) presented to the clinic in January 2021 for painful oral and anal ulcers. He was managed with reduced maintenance immunosuppression, filgrastim, lidocaine-diphenhydramine-corticosteroid oral rinse, and topical nitroglycerin-nystatin ointments without relief. He returned to the emergency department in February for worsening pain, facial swelling, inability to open mouth, and difficult defecation. Inpatient evaluation demonstrated neutropenia (0.8/μL), lymphopenia (0.5/μL), and elevated inflammatory markers [ESR: 119 mm/h; CRP: 123.2 mg/L; procalcitonin: 0.14 ng/mL]. However, blood culture, serology for Epstein-Barr virus, herpes simplex virus, cytomegalovirus, head-neck and chest imaging, esophagogastroduodenoscopy, perianal punch biopsy, and anal canal incisional biopsy were unremarkable. Importantly, serum voriconazole level was elevated (7.2 μg/mL). Discontinuation of voriconazole led to relief in symptoms and discharge. On clinic follow-up, he endorsed complete resolution of ulcers. Of note, his antifungal prophylaxis was temporarily switched from isavuconazole to voriconazole in January. DISCUSSION: Voriconazole-induced photosensitivity and elevated plasma retinol levels may progress to cutaneous malignancies. In our patient, temporality of onset (one week) and resolution (within days) of mucosal ulceration with voriconazole discontinuation suggest an association. No residual scarring or recurrence was observed. CONCLUSIONS: Physicians must be mindful of dermatologic adverse events of voriconazole in LTx recipients. DISCLOSURE: Nothing to declare. KEYWORD: Lung transplantation