A Case of Successful Treatment of Cutaneous Aspergillosis with Voriconazole at the Low Cyclosporine Trough Level in a Renal Transplant

Aspergillosis is a serious infectious complication with high mortality in transplant recipients. Voriconazole is a broad spectrum triazole antifungal agent, but it has a drug-drug interaction with immunosuppressants. Herein we report a case of the use of a small dose of cyclosporine (CsA) with coadministration of voriconazole. A 23 year old woman received a kidney transplant from a deceased donor. The initial immunosuppressant was tacrolimus, mycophenolate mofetil, steroids, and basiliximab. Thirty-two days after kidney transplantation, because of hemolytic uremic syndrome, she received Rabbit anti-human thymocyte immunoglobulin and plasmapheresis. Cyclosporine was used instead of tacrolimus. Three months after transplantation, she was admitted to the hospital because of an erythematous nodule on her trunk and a dry cough. Skin biopsy revealed an Aspergillus species and tissue culture showed that it was A. fumigatus. We treated her with itraconazole and subsequently with amphotericin B. Afterwards, her condition got worse. So we changed amphotericin B to voriconazole and a minimum dose of CsA (25 mg bid) at the peril of graft failure. Eventually, she recovered and maintained good graft function. The trough level of CsA ranged from 3.2 to 27.9 ng/mL.