Introduction: Invasive fungal infections are a major source of morbidity and mortality after liver transplantation. Candida auris and Mucorales species pose distinct challenges, including drug resistance, delayed diagnosis, and limited treatment options. Fosmanogepix, a novel antifungal targeting the fungal enzyme Gwt1, is under investigation for multidrug resistant infections. We present a rare case of drug-resistant Candida auris (C. auris) and Mucor circinelloides (M. circinelloides) bloodstream and intraabdominal infection after liver transplant treated with the novel antifungal agent fosmanogepix.
Description: A 52-year-old man with metabolic dysfunction-associated steatotic liver disease and alcoholic cirrhosis underwent orthotopic liver transplantation complicated by primary graft nonfunction, requiring retransplantation. His postoperative course was further complicated by a persistent abdominal wall infection involving drug-resistant C. auris and M. circinelloides, unresponsive to amphotericin B, micafungin, and posaconazole. Infection was suspected to be associated with retained Gore-Tex mesh. He also developed respiratory failure requiring tracheostomy. After six weeks of ineffective antifungal therapy, fosmanogepix was initiated under expanded access. Within 18 days, beta-D-glucan levels decreased from 204 to 121 pg/mL, and cultures confirmed susceptibility to fosmanogepix. Following clinical improvement, he transitioned to a prolonged course of amphotericin B. This case highlights a rare use of fosmanogepix in a liver transplant patient with concurrent drug-resistant fungal infection.
Discussion: Although a single case cannot establish efficacy, the rarity of concurrent C. auris and M. circinelloides infection in a liver transplant recipient and the increasing prevalence of multidrug resistant fungal pathogens support the need to highlight emerging therapies. This patient failed conventional treatment and showed clinical improvement and microbiologic response after fosmanogepix was initiated under expanded access. The observed decline in beta-D-glucan and transition to oral therapy contributed to infection control and stabilization. Fosmanogepix may provide a much-needed alternative for transplant recipients with multidrug resistant fungal infections unresponsive to existing therapies.
