Successful Management of Aspergillus Liver Abscess in a Patient with Necrotizing Fasciitis

Excerpt

Invasive Aspergillus infections are among the infectious diseases with the highest mortality and mainly cause diseases in immunocompromised hosts [1, 2]. Notably, the organism can also cause severe surgical site infections [3‐5]. As filamentous fungi are airborne pathogens, in most cases pulmonary infection represents the initial manifestation, with subsequent spread to other organs if the infection cannot be controlled at an early stage [6]. Therefore, liver aspergillosis is seen in most cases if the fungus causes disseminated disease. Liver abscesses of other origin are extremely rare [7, 8]. The spread from an intra-abdominal site through the portal vein is even less likely. Open abdominal treatment is a viable option to control severe intra-abdominal infection or pancreatitis and is also indicated in the case of necrotizing fasciitis of the abdominal wall [9]. The vacuum-assisted closure (VAC) system has been shown to be a useful tool in this setting [10]. The large surface of the wound allows for colonization by a multitude of pathogens [11]. Although bacteria are the organisms most frequently isolated, in some cases fungi have been reported. Filamentous fungi rarely colonize such wounds, and it is not clear if this requires antifungal therapy [12]. Patients who need open abdominal treatment should be considered immunocompromised, and therefore, local and systemic host defense may be unable to control fungal colonization [13]. It is unclear if topical application of disinfecting or antifungal agents is sufficient or if systemic antifungal agents should be applied to prevent spread of the organisms. Amphotericin B is the antifungal agent with the broadest spectrum of activity, but it is associated with significant nephrotoxicity and its lipid formulations are rather expensive agents [14]. The new agents caspofungin and voriconazole have demonstrated good in vitro activity against Aspergillus species and both drugs have shown efficacy in the treatment of invasive aspergillosis [15‐17]. Nevertheless, mortality rates remain unsatisfactorily high when used as single agents. Only little data on combination therapy using voriconazole and caspofungin are available [18, 19]. For patients with Aspergillus surgical infections, even less data are currently available. We report on a patient who developed Aspergillus liver abscesses and was successfully treated by combination therapy with voriconazole and caspofungin. …