1. Heroic interventions for an infectious complication in a lung transplant recipient Jutta Preiksaitis Karen Doucette

2. Case Summary 23F with CF, DLuTx Oct 2008 – Colonized with P. boydii pre-Tx. On voriconazole pre- Tx ( 2005, 2007) and 6 weeks of Caspofungin + voriconazole peri-op Oct/09 admitted with back pain, MRI demonstrated discitis/OM T12-L1. CT guided biopsy negative bacterial and fungal cultures – Treated empirically with Cefazolin/Cephalexin, ciprofloxacin and voriconazole ( 6 months) – Clinical resolution and stable MRI follow up to May/13

3. Jan 2014 Presented with recurrent back pain and MRI back ( no OM), subsequently CT abdomen: Large abdominal aortic aneurysm (8.0 x 9.5cm T9-L3), likely mycotic, bcx neg Rx: Voriconazole, vancomycin, ceftriaxone

4. OR March 2014 Dacron graft from distal aortic arch extending infra-renally with replacement of visceral artery roots Scedosporium apiospermum isolated from all segments of aorta and visceral segments sampled

5. What is appropriate anti-fungal therapy in this setting? voriconazole and terbinafine Voriconazole 600 BID to get therapeutic level (5.7μg/ml)

6. Complication: bleeding April 2014 – back pain, retroperitoneal hematoma, embolization bleed and embolization of celiac axis ( source: pseudoaneruysm celiac artery)

7. More complications subacute fluoride toxicity from voriconazole Micafungin added after first bleed Developed severe diffuse, incapacitating bone pain and rising liver enzymes mid-June Posaconazole substituted for voiconazole (Level – 1.7 μg/ml)

8. Another bleed August 2014– chest pain, L hemothorax, source: pseudoaneruysm proximal anastomosis, surgery with placement of 2 endovascular stents Remains on posaconazole ( levels ~1.0-1.2 μg/ml ) and micafungin, stable over the last year

9. Scedosporium aortitis References Thomson S, Alibhal K, Winkelaar et al: Case report of vertebral osteomyelitis and mycotic abdominal aortic aneurysm caused by Scedosporium apiospermum in a lung transplant patient with cystic fibrosis Tranplant Proc 2015;47:204-209 Ong A, Blyth C, Bency et al Fatal Mycotic Aneurysms due to Scedosporium J Clin Microbiol 2011;49:2067-71 Tortorano AM, Richardson M, Roilides E et al. RSMID and ECMM joint guidelines on diagnosis and management of hyalohyphomycosis: Fusarium spp., Scedosporium spp. and others Clin Microgiol Infect 2014;20 (suppl 3):27-46 Tedja R, El-Sherief A, Olbrych T, Gordon S. Multi-focal periostitis as a complication of chronic use of voriconazole in a lung Tx recipient. Transpl Infect Dis ;15:424- 429.