Voriconazole-induced hepatotoxicity resolved after switching to amphotericin b in fusarium dimerum central line-associated bloodstream infection

Abstract

Background: Fusarium spp. is a rare cause of opportunistic life-threatening fungal infections. It has a remarkably high re-sistance profile with few effective antifungal agents, mostly limited to voriconazole and liposomal amphoter-icin B. Drug-induced liver injury (DILI) by 1 of these 2 antifungal agents further complicates the management of these infections. A 38-year-old woman with short bowel syndrome presented to the hospital with concerns of abdominal pain and loose stools. An abdominal CT was negative for inflammatory or ischemic bowel disease, and there was no evidence of liver disease. She tested positive for SARS-CoV-2 and required transfer to the ICU due to hy-potension requiring fluid resuscitation and vasopressors. On day 43 of her admission, the patient developed a low-grade fever, for which she underwent central-line and peripheral-blood cultures that were positive for Fusarium dimerum. The central line was removed and i.v. voriconazole was started. After 3 days of treatment, the patient’s liver enzymes rose abruptly. Voriconazole was discontinued and replaced with liposomal ampho-tericin B, and the liver enzymes improved significantly. The patient completed 14 days of therapy and was discharged from the hospital. This is a case of F. dimerum infection followed by DILI from voriconazole treatment. Her infection was resolved after switching to liposomal amphotericin B, with improvement in liver enzymes on day 1 after discontinuing voriconazole. This observation demonstrates that altering antifungal classes may be an appropriate strategy when confronted with DILI.