Successful Treatment of Paecilomyces variotii Pneumonia and Lupus Nephritis With Posaconazole-Cyclophosphamide Co-administration Without Drug Interaction-Induced Toxicity

Joseph Pechacek; Taura Webb; Elise M N Ferré; Monica M Schmitt; Thomas DiMaggio; Dale Kobrin; Suraj Rajasimhan; Ben Colton; Russell E Lewis; David Andes; Alejandro Herrera; Dima Hammoud; Seyedmojtaba Seyedmousavi; Sarfaraz Hasni; Jonathan Bolaños; Behdad Afzali; Michail S Lionakis

doi:10.1093/ofid/ofad410

Successful Treatment of Paecilomyces variotii Pneumonia and Lupus Nephritis With Posaconazole-Cyclophosphamide Co-administration Without Drug Interaction-Induced Toxicity

Open Forum Infect Dis. 2023 Aug 2;10(8):ofad410. doi: 10.1093/ofid/ofad410. eCollection 2023 Aug.

Authors

Joseph Pechacek¹, Taura Webb^{1

2}, Elise M N Ferré¹, Monica M Schmitt¹, Thomas DiMaggio¹, Dale Kobrin³, Suraj Rajasimhan⁴, Ben Colton⁴, Russell E Lewis⁵, David Andes⁶, Alejandro Herrera⁷, Dima Hammoud⁸, Seyedmojtaba Seyedmousavi⁹, Sarfaraz Hasni³, Jonathan Bolaños², Behdad Afzali², Michail S Lionakis¹

Affiliations

¹ Fungal Pathogenesis Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA.
² Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA.
³ Lupus Clinical Trials Unit, National Institute of Arthritis and Musculoskeletal and Skin Disease, National Institutes of Health, Bethesda, Maryland, USA.
⁴ Pharmacy Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA.
⁵ Dipartimento di Medicine Molecolare, University of Padua, Padua, Italy.
⁶ Division of Infectious Diseases, Department of Medical Microbiology and Immunology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA.
⁷ Virtua Infectious Disease, Virtua Voorhees, Virtua Medical Group, Vorhees, New Jersey, USA.
⁸ Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Maryland, USA.
⁹ Microbiology Service, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA.

Abstract

Paecilomyces variotii is an opportunistic mold that causes pulmonary infections in immunosuppressed humans that are often treated with triazole therapy. Lupus nephritis is a major cause of progressive kidney disease in patients with systemic lupus erythematosus, often requiring cyclophosphamide-based therapies. Triazole-cyclophosphamide co-administration is challenging as triazoles increase cyclophosphamide concentrations, which can worsen cyclophosphamide toxicity. We describe herein a patient with Paecilomyces variotii pneumonia and concomitant lupus nephritis who was successfully treated with posaconazole and echinocandin-bridged interruptions to allow for cyclophosphamide therapy. This regimen was well-tolerated without cyclophosphamide toxicity and achieved improvements in both fungal pneumonia and renal function.

Keywords: Paecilomyces; cyclophosphamide; drug–drug interactions; lupus nephritis; posaconazole.

Published by Oxford University Press on behalf of Infectious Diseases Society of America 2023.

Publication types

Case Reports