Invasive fungal infections pose significant morbidity and mortality risks, particularly those caused by moulds. Available antifungal classes are limited by toxicities and are increasingly susceptible to resistance, particularly amongst challenging fungal pathogens. The purpose of this case series and literature review was to characterize the use of a high-dose lipid formulation of amphotericin B. A case series is presented including patients who received high-dose lipid formulation amphotericin B (≥7.5 mg/kg/day) between June 2012 and August 2021. Additionally, a systematic literature review was conducted by searching the PubMed database for English-language studies involving individuals who received high-dose amphotericin B therapy (≥7.5 mg/kg) using lipid formulations. Nine patients were included in the case series, receiving an average of 8.9 ± 1.3 mg/kg liposomal amphotericin B over a mean of 11.0 ± 10.8 days predominantly for mould infections including Mucorales, aspergillosis and Fusarium. The patients were primarily cared for in intensive care units, with varying treatment histories and outcomes. A total of 11 studies (n=260 patients) met inclusion criteria for the literature review. Responses to high-dose liposomal amphotericin B ranged from 8% to 100%, often showing favourable outcomes. High doses of liposomal amphotericin B were well tolerated both in the case series and in published literature, with serum creatinine changes being the most commonly reported adverse event. However, multi-patient studies continue to report less than favourable (range 8-62%) response rates. High-dose liposomal amphotericin B, either alone or in combination with other antifungal agents, might be a viable strategy for managing invasive fungal infections when few treatment choices exist. This article is part of the Challenges and strategies in the management of invasive fungal infections Special Issue: https://www.drugsincontext.com/special_issues/challenges-and-strategies-in-the-management-of-invasive-fungal-infections.

Kodamaea ohmeri (K. ohmeri) is an ascosporogenic species of yeast that belongs to the genus Ascosporogenous and the family of Saccharomycetaceae. It has recently been found to cause various types of infections, particularly in critically ill immunocompromised patients. The present study describes a case of hospital-acquired pneumonia caused by K. ohmeri during veno-arterial extracorporeal membrane oxygenation. The fungal culture turned negative after the administration of caspofungin and amphotericin B. Extracorporeal membrane oxygenation (ECMO) is an adjunctive medical technique that provides temporary cardiopulmonary support for patients. Previous observations have suggested that the immune function of patients will typically decline during the use of ECMO, rendering infection to be one of the main complications of ECMO. K. ohmeri is a rare pathogenic fungus, particularly in immunocompromised individuals with vascular catheters, while amphotericin B is the most common antifungal therapy administered to treat K. ohmeri infections. It is important to raise awareness of rare fungal infections and actively treat them.

Cryptococcal meningitis represents a severe opportunistic fungal infection primarily observed in individuals with compromised immune systems. It frequently manifests in symptoms like headaches, vomiting, cranial nerve complications, and cognitive alterations. However, it\'s worth noting that up to 15% of cases may exhibit no discernible central nervous system-related symptoms. A 70-year-old male, previously diagnosed with pulmonary tuberculosis and undergoing treatment with anti-tubercular medications, was admitted due to changes in consciousness, sporadic low-grade fever, and cognitive impairment. An in-depth investigation revealed his HIV-negative and non-diabetic status, as well as his preserved immune competence. A plain CT head showed a communicating hydrocephalus and a lumbar puncture was positive for Cryptococcus neoformans. Treatment commenced with an induction regimen encompassing amphotericin and fluconazole, concurrently maintaining the anti-tubercular treatment course. The patient\'s condition displayed improvement, leading to a transition to a maintenance dosage of fluconazole. This case highlighted an extraordinary occurrence of Cryptococcal meningitis in an HIV-negative patient with no history of immunosuppressant use. Notably, Cryptococcal infection should be regarded as a primary consideration in patients afflicted by pulmonary tuberculosis who subsequently present with altered consciousness. The timely identification and proper management of such instances can substantially mitigate the risks of mortality and morbidity associated with this condition.

Mucormycosis is an opportunistic fungal infection which was earlier seen only in immunocompromised patients. With the recent covid pandemic, there had been a drastic surge in cases of mucormycosis worldwide and especially in India. Here, we present an unusual case of biopsy proven invasive mandibular mucormycosis in a patient with chronic kidney disease and a history of COVID-19 infection. The patient was given low-dose amphotericin B and underwent surgical debridement with a successful outcome.

Although the treatment of aspergillosis has been studied for years, the optimal nonsurgical treatment of chronic cavitary pulmonary aspergillosis (CCPA) remains unsatisfactory, especially in lung cancer. We report two advanced non-small cell lung cancer (NSCLC) patients who recovered from CCPA following instillation of Amphotericin B (AmB) by bronchoscopy combined with systemic voriconazole. The first patient was diagnosed with lung adenocarcinoma after right upper lobe resection and was treated with anaplastic lymphoma kinase-targeted therapy. Chest computed tomography (CT) revealed a right pulmonary cavity containing solid materials. The second patient was diagnosed with squamous cell carcinoma and received immunotherapy following surgery, chemotherapy, and radiotherapy. Chest CT tomography revealed a mass in the right lung cavity. Both patients\' cultures and next-generation sequencing of their bronchoalveolar lavage (BAL) samples revealed presence of Aspergillus fumigatus. In addition, the galactomannan test of both patients BAL samples was positive. Systemic voriconazole was prescribed based on in vitro susceptibility testing. The chest images and clinical symptoms of both patients did not improve after one month of voriconazole therapy within the therapeutic blood concentration. Considering the low local concentrations of antifungals against CCPA, AmB instillation by bronchoscopy combined with systemic voriconazole was utilized. The chest CT images and clinical symptoms of both patients markedly improved in the following third month. Instillation of AmB combined with systemic voriconazole may be a promising treatment option for NSCLC patients with CCPA who fail voriconazole monotherapy.

Cutaneous chromoblastomycosis is a chronic subcutaneous fungal disease of the skin caused by Blastomyces dermatitidis, especially by Fonsecaea, Phialophora,and Cladophialophora species affecting the skin, lungs, intestines, stomach, and central nervous system. It is treated using itraconazole in mild cases and amphotericin B in severe cases. A six-year-old female child presented to the Dermatology Outpatient Department with pigmented brown to blackish tanned plaques and verrucous lesions on the face and extremities. These lesions were present for the past two and a half years and were slowly enlarging and involving other areas like the trunk. The lesions were proven on biopsy to be cutaneous blastomycosis. The patient was put on infusions of amphotericin B in a calculated pediatric dose. Her blood pressure and renal function tests were checked daily to avoid any electrolyte derangements, nephrotoxicity, and systemic infusion reactions caused by amphotericin B. Amphotericin B reduced the size of the cutaneous lesions, and treatment response was assessed on regular follow-ups. Chromoblastomycosis should be considered in the differential diagnosis to enable timely treatment and to prevent its lethal complications such as epidermoid carcinoma. Treatment should continue for two to three months until histopathology is negative to ensure complete eradication.

UNASSIGNED: In an immunocompromised patient, there has never been a report of Epstein-Barr virus (EBV) and Talaromyces marneffei co-infection. Treatment with intravenous ganciclovir for EBV-associated uveitis has only been explored in a few cases.
UNASSIGNED: A 47-year-old HIV-positive female presented with scleral nodule and vascularized iris tumor in the left eye. After the ancillary laboratory workup, EBV was detected by polymerase chain reaction on aqueous humor and scleral tissue analysis. The lesion subsided completely with systemic and local ganciclovir therapy. Subsequently, recurrent scleral nodule with iris plaque developed and was pathologically diagnosed as Talaromyces marneffei. The employed treatment, including intravenous amphotericin B and intracameral amphotericin B injection, was successful in attaining a significant regression of the lesion.
UNASSIGNED: Although EBV treatment is debatable, our combination of systemic and local ganciclovir therapy demonstrated regression of EBV-caused scleral nodule and iris plaque. The organism\'s identification was complicated by Talaromyces marneffei, but it was easily treated.
UNASSIGNED: In HIV-infected patients, EBV-associated sclerouveitis can be successfully treated with systemic and local ganciclovir therapy, and there is a possibility of coinfection with Talaromyces marneffei.

Fungal infections due to Fusarium species are serious albeit rare and mostly occur in severely immunocompromised patients. The prognosis of such infections, especially of disseminated manifestations, is poor as a result of multi-antifungal resistance, particularly to azoles. We report a case of a rapidly progressive necrotizing fasciitis of the foot secondary to Fusarium solani in a young female patient with acute lymphoblastic leukemia on consolidation therapy. Surgical debridement was undertaken and liposomal amphotericin was given as definitive therapy for a total of six weeks followed by secondary prophylaxis that resulted in remarked clinical and radiological improvement. High clinical suspicion, prompt surgical intervention, rapid diagnosis, and timely initiation of appropriate antifungal therapy are crucial for a favorable outcome in this relatively uncommon life-threatening infection.

Mucormycosis is a fungal infection that can be very destructive and often fatal. People most prone to this infection include those who are immunocompromised. Early diagnosis and treatment, along with addressing the risk factors, play a pivotal role in the management. Here, the authors are reporting three cases of immunocompromised patients. Among them, two had uncontrolled diabetes, and the third had a history of renal transplant and COVID-19 infection. All three cases are distinct anatomically; one is pulmonary, one is rhino-orbital-cerebral, and the last one is rhino-maxillary.

BACKGROUND: Liposomal amphotericin B is a widely used broad-spectrum antifungal drug. It was developed to reduce nephrotoxicity and maximize the therapeutic utility of amphotericin B in the treatment of invasive fungal infections. Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a severe drug-induced hypersensitivity syndrome commonly associated with aromatic antiepileptic drugs. Liposomal amphotericin-B was associated with DRESS syndrome in only one case.
METHODS: We report an exceptional case of possible DRESS syndrome associated with liposomal amphotericin B in a 31-year-old male renal transplant recipient. Seventeen days after starting liposomal amphotericin B for visceral leishmaniosis, he developed a skin rash with elevated liver tests. Liposomal amphotericin B was then discontinued. A favourable outcome was slowly observed in one month.
CONCLUSIONS: This case scored two (possible case) based on the criteria adopted by the European group RegiSCAR. The Naranjo score for liposomal amphotericin B was four (possible).