C297 - Cerebral Sporotrichosis in a Transplant Recipient: A Case Report

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Author Block: I. Hunter¹, M. E. Salam², M. Casias², B. McCollister¹, C. Chiu¹, ¹University of Colorado, Aurora, CO, ²Pharmacy, UCHealth, Aurora, CO
*Purpose: Sporotrichosis most commonly causes cutaneous disease, but in immunocompromised individuals, it can become disseminated. Itraconazole is the first-line therapy for cutaneous sporotrichosis, but the optimal drug for central nervous system (CNS) infection remains unknown.
*Methods: We present a case of CNS sporotrichosis in a transplant recipient and the literature review.
*Results: A 51-year-old female underwent simultaneous liver and kidney transplantation in 2019 and was maintained on immunosuppression with tacrolimus, mycophenolate mofetil, and prednisone. Over a period of four months, she developed worsening headache and nausea, which progressed to left-sided weakness. Brain MRI revealed a right thalamic infarction with obstructive hydrocephalus and basilar dural/leptomeningeal enhancement (Fig 1A). An external ventricular drain was placed, and cerebrospinal fluid culture grew Sporothrix species (Fig1B). The patient denied any gardening work or exposure to animals. A thorough skin examination did not reveal any lesions On hospital day 6, liposomal amphotericin B and isavuconazonium (Cresemba) were initiated. By day 37, despite stable serial brain imaging and no additional molds identified in CSF samples, the patient’s mental status deteriorated, leading to the initiation of high-dose dexamethasone for its anti-inflammatory effects. On hospital day 39, antifungal susceptibility testing of the Sporothrix isolate revealed the following minimum inhibitory concentrations: amphotericin B 4, itraconazole 0.5, posaconazole 1, voriconazole >16, and isavuconazole >16 μg/mL. Based on these results, antifungal therapy was adjusted to posaconazole and liposomal amphotericin B. On day 88, the patient had a fatal asystolic cardiac arrest in the context of shock secondary to hospital-acquired Pseudomonas aeruginosa pneumonia.
*Conclusions: Around 50 cases of CNS sporotrichosis have been reported in the literature, with fewer than 20 documented in the U.S. The most common neurological manifestation is chronic headache (83%), often accompanied by cutaneous lesions (81%). CNS involvement occurs predominantly in immunocompromised hosts, particularly those with HIV infection (85%). The overall reported mortality is 56%. The distinctive feature of our case is the occurrence of an isolated ischemic lesion in a transplant recipient without cutaneous manifestations. Liposomal amphotericin B remains the mainstay of therapy for mold-related CNS infections. However, the role of concomitant or step-down antifungal therapy in CNS sporotrichosis remains uncertain.