Breakthrough fusariosis in a patient with acute lymphoblastic leukemia receiving voriconazole prophylaxis.

nema pallidum antibody, and a diagnosis of relapsed secondary syphilis was made. Syphilitic hepatitis was suspected on the basis of a 2-fold increase in the level of alkaline phosphatase from previously normal levels, a 2-fold increase in the level of liver enzymes from baseline, a 5-fold increase in total bilirubin to 1200 mmol/L, and the exclusion of other etiologies, including viral hepatitis (A and B) and alcohol abuse. Two hours after the patient received intramuscular penicillin V, his temperature increased to 39.0ЊC. Within 24 h, the AST and ALT levels had increased to 1331 U/L and 328 U/L, respectively, and by 36 h, the patient was encephalopathic, with an international normalized ratio of 2.16, a total bilirubin of 364 mmol/L (direct bilirubin, 197 mmol/L). A diagnosis of Jarisch-Herxheimer reaction was made. Over the next week in the intensive care unit, the patient's condition and liver status stabilized. Further antibiotic therapy for syphilis was administered without incident. The patient was eventually discharged but died of decompensated liver disease 6 months later. Syphilitic infection of the liver is well documented [4–6]. This case illustrates the potential for hepatic complications resulting from syphilitic infection and its treatment in cases of HIV-HCV coinfec-tion. Liver injury due to syphilis is thought to be immune mediated, although obstruction of portal lymph nodes by syph-ilitic adenitis has been proposed. The histological findings are variable and non-specific and include portal inflammatory infiltrates, hepatocellular necrosis, granu-loma, and cholestatis. There is insufficient knowledge of the effects of HIV infection, if any, on the histological manifestations of syphilitic hepatitis. The Jarisch-Herxheimer reaction is clearly life-threatening in patients with preexisting cirrhosis and limited hepatic synthetic reserve. The rapid lysis of spi-rochetes releases heat-stable pyrogen, which produces this febrile illness. It is unclear what influence HIV-related immune suppression has on the severity of this reaction. It is noteworthy that among an HIV-seropositive cohort with syphilitic hepatitis (), no one developed a Jar-n p 7 isch-Herxheimer reaction [7]. Acute hepatitis C in HIV-infected men who have sex with men. HIV Med 2004; 5:303–6. 4. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 27-1983: a 25-year-old homosexual man with persistent fever and liver disease. Sir—Voriconazole is a broad-spectrum triazole antifungal drug with excellent activity against Aspergillus species, most Candida species, and several less-common invasive fungi but with limited activity against pathogenic Zygomycetes. Reports on the successful use of voriconazole therapy for patients …