P311 First reported case of Cladosporium liver abscess in immunocompromised host
Authors: Xuan Tuang Wei , Sivakumar Palaniapan , Petrick Periyasamy 
Published: September 2022

Abstract

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

Background
Cladosporium species are ubiquitous, saprobic, dematiaceous fungi that are infrequently associated with human opportunistic infections. They are usually associated with allergic rhinitis, asthma, localized superficial, and deep cutaneous and subcutaneous lesions, but rarely cause disseminated infection, known as phaeohyphomycoses.

Case Description
We report a case of Cladosporium liver abscess in an immunocompromised host. A 39-year-old male with a history of multiple sexual partners was newly diagnosed with human immunodeficiency virus and was antiretroviral therapy naïve. He presented with epigastric and right hypochondriac pain, associated with abdominal distension for 3 months. On examination, he was jaundiced with hepatomegaly. Full blood count showed leukocytosis with neutrophilia (TWC 14.3 × 109/l with ANC 11.2 × 109/l). The liver function test shows hyperbilirubinemia with obstructive features. (Total bilirubin 101.9 μmol/l, direct bilirubin 78.8 μmol/l, ALT 87 U/l, AST 168 U/l, ALP 383 U/l, INR: 1.37). Baseline CD4 was 41 cells/ul, and HIV viral load was &gt;10 000 000 copies/mL.
CECT 4-phase liver shows enlarged liver with smooth lobulated margin, measured 22.5 cm. Multiple large round hypodense masses of varying sizes were seen scattered in both liver lobes. The largest mass is in segment VII measuring 5.8 × 7.7 × 8.8 cm. Liver biopsy showed evidence of diffuse large B cell lymphoma while tissue fungal culture grew Cladosporium sp. Antifungal susceptibility testing showed a low MIC range for posaconazole, voriconazole, and itraconazole while terbinafine was not tested. Patient received tablet voriconazole 200 mg BD for 3 months. He was also initiated on chemotherapy antiretroviral therapy at the same time with the regime of T. Tenofovir disoproxil fumarate/emtricitabine 1 tablet once daily and tablet dolutegravir 50 mg once daily. A repeated PET-CT done 3 months later during chemotherapy shows residual hypodense liver lesions.

Discussion
A wide range of fungi can be found on various human mucosal surfaces, such as lungs, vaginal tract, urinary tract, oral cavity, intestines, and skin. The community of commensal fungi interacts with commensal bacteria and the host. Changes in the commensal fungi have a significant impact on host health and are associated with pathological conditions. Cladosporium was reported as one of the commensal fungi. Reports of invasive Cladosporium infection are extremely rare with variable presentation. There were previous case reports of Cladosporium infection of the central nervous system, lung, and skin but no liver abscess has been reported yet. Fungal hepatic abscesses are not uncommon among immunocompromised hematological malignancy patients, especially those with leukemia and prolonged neutropenia. Azoles, particularly itraconazole, and posaconazole have good activity against Cladosporium species, although voriconazole displayed variable activity. This is consistent with our case whereby itraconazole and posaconazole demonstrate the lowest MIC as compared to voriconazole. However, voriconazole was chosen instead of itraconazole for coverage against the possibility of Aspergillus appearing later. In our case, the patient showed a good response to voriconazole.

Conclusion
The choice of antifungal will depend on susceptibility testing, organ involvement, tissue bioavailability, drug-drug interaction, and patients’ clinical risk factors; whereas the duration of treatment is guided by radiological resolution and control of risk factors.