C299 - Cladophialophora Bantiana Cerebral Phaeohyphomycosis in Solid Organ Transplant Recipients: First Case Treated with Fosmanogepix and Systematic Review of the Literature

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Author Block: M. Taman¹, A. A. Teshome¹, C. Porto¹, D. Farmakiotis², A. N. Malik¹, ¹The Warren Alpert Medical School of Brown University, Providence, RI, ²Beth Israel Deaconess Medical Center, Providence, RI
*Purpose: Cladophialophora bantiana is a neurotropic mold causing highly lethal brain abscesses, especially in the immunosuppressed. Management is challenging and limited by CNS drug penetration and toxicity. We report the first case in an organ transplant (OT) recipient successfully treated with fosmanogepix (FMGX) and review published cases associated with OT.
*Methods: A renal transplant recipient with C. bantiana abscess underwent serial resections, Ommaya-directed amphotericin-B instillation, and received FMGX, a CNS-penetrant Gwt1 inhibitor, under compassionate use, due to voriconazole life-threatening toxicity. A PRISMA-guided PubMed and Embase review (through May 2025) identified OT-associated C. bantiana CNS infections, extracting demographics, transplant type, antifungal regimen, surgical approach, and outcomes.
*Results: The index patient achieved complete microbiologic and radiographic cure after staged resections and along with FMGX, with sustained recovery at 2 years, one already without any antifungal treatment. Literature review identified 22 cases in OT (16 kidney, 3 liver, 2 lung, 1 heart) recipients; overall survival was 27.3%. All survivors underwent resection; none of 6 medically managed patients survived. Gross-total resection yielded the best survival (57%) versus subtotal (20%) or aspiration (0%). Combination antifungal therapy (82%), typically amphotericin B ± voriconazole ± flucytosine, was common. Intracavitary therapy was rarely used (3 cases, all fatal). In our patient, FMGX was well-tolerated without toxicity.
*Conclusions: C. bantiana brain abscesses remain highly fatal, with just over one of four OT recipients cured. Outcomes improve with maximal-safe resection. FMGX is a promising agent for salvage or stepdown therapy, whereas in situ antifungals merit further investigation.