Fusarium is a fungal pathogen of immunosuppressed lung transplant patients associated with a high mortality in those with severe and persistent
neutropenia. The principle portal of entry for Fusarium species is the airways, and lung involvement almost always occurs among lung transplant patients with disseminated
infection. In these patients, the immunoprotective mechanisms of the transplanted lungs are impaired, and they are, therefore, more vulnerable to
Fusarium infection. As a result,
fusariosis occurs in up to 32% of lung transplant patients. We studied
fusariosis in 6 patients following
lung transplantation who were treated at Massachusetts General Hospital during an 8-year period and reviewed 3 published cases in the literature. Cases were identified by the microbiology laboratory and through discharge summaries. Patients presented with
dyspnea,
fever, nonproductive
cough,
hemoptysis, and
headache. Blood tests showed elevated white blood cell counts with granulocytosis and elevated inflammatory markers. Cultures of Fusarium were isolated from bronchoalveolar lavage, blood, and sputum specimens.Treatments included
amphotericin B,
liposomal amphotericin B,
caspofungin,
voriconazole, and
posaconazole, either alone or in combination. Lung involvement occurred in all patients with disseminated disease and it was associated with a poor outcome. The mortality rate in this group of patients was high (67%), and of those who survived, 1 patient was treated with a combination of
amphotericin B and
voriconazole, 1 patient with
amphotericin B, and 1 patient with
posaconazole. Recommended empirical treatment includes
voriconazole,
amphotericin B or
liposomal amphotericin B first-line, and
posaconazole for refractory disease. High-dose
amphotericin B is recommended for treatment of most cases of
fusariosis. The
echinocandins (for example,
caspofungin,
micafungin,
anidulafungin) are generally avoided because Fusarium species have intrinsic resistance to them. Treatment should ideally be based on the Fusarium isolate, susceptibility testing, and host-specific factors. Prognosis of
fusariosis in the immunocompromised is directly related to a patient's immune status. Prevention of
Fusarium infection is recommended with aerosolized
amphotericin B deoxycholate, which also has activity against other important fungi.