A case report of intravenous posaconazole in hepatic and renal impairment patient with invasive Aspergillus terreus infection: safety and role of therapeutic drug monitoring

Abstract

Background: Invasive aspergillosis (IA) is a fatal infectious complication among immunocompromised patients. Aspergillus terreus, the fourth common species can be difficult to treat due to a unique resistance pattern. To date, there has been no report on safety and dose adjustment when intravenous posaconazole is selected in hepatic and renal impairment patient. We present a rare case of intravenous posaconazole use in a hepatic and renal impairment patient with invasive A. terreus pulmonary infection. To our knowledge, this is the first report of intravenous posaconazole use in IA due to A. terreus with hepatic and renal impairment focusing on drug safety and role of therapeutic drug monitoring (TDM). Case presentation: A 37-year-old previously healthy man with diagnosis of dengue hemorrhagic fever and shock complicated with hepatic and renal impairment proposed to have proven invasive A. terreus pulmonary infection is described. Due to lack of good clinical response and concern of potential adverse effects whilst on intravenous voriconazole, intravenous posaconazole 300 mg every 48 h was chosen with confirmed therapeutic plasma concentrations. Despite the death of the patient and IA deemed uncontrollable, there were no significant side effects attributable to intravenous posaconazole use demonstrated over a period of 34 days. Conclusions: Intravenous posaconazole use with TDM implementation maybe a safe alternative option to standard therapy. Therapeutic plasma posaconazole level may be reached at lower dosing regimen in renal and hepatic impairment patient. However, explanations of clinical failure on this patient with immunodeficiency state were multifactorial.