How do you treat a 25-year-old male with positive automatism and presence of Pullulans (a type of fungus) and saprophytic fungus?

Treatment of Aureobasidium Pullulans and Saprophytic Fungal Infection

Voriconazole is the first-line treatment for Aureobasidium pullulans and saprophytic fungal infections in a 25-year-old male with positive automatism. 1

Diagnostic Approach

Before initiating treatment, a thorough diagnostic workup should be performed:

1. Blood tests:

   • Full blood count to rule out underlying blood disorders
   • Fasting blood glucose (hyperglycemia is a predisposing factor for invasive fungal infections)
   • HIV antibody and syphilis serology to exclude these infections 2

2. Microbiological confirmation:

   • Isolation of the fungus is crucial due to variable susceptibility to antifungal agents 2
   • Collect appropriate specimens for fungal culture before starting antifungal therapy

3. Biopsy may be necessary if the diagnosis remains uncertain 2

Treatment Protocol

First-line Treatment

• Voriconazole:
  • Loading dose: 400 mg (6 mg/kg) every 12 hours on day 1
  • Maintenance: 200 mg (3-4 mg/kg) twice daily 3
  • Therapeutic drug monitoring is recommended to ensure adequate serum levels

Alternative Options

• Itraconazole: Can be considered as an alternative if voriconazole is not tolerated 2

• Posaconazole: Useful third-line agent for those with adverse events or clinical failure 2

• For resistant infections:

  • Combination therapy with voriconazole plus terbinafine may be effective 2
  • Echinocandins (caspofungin, micafungin) can be considered in cases of azole resistance 2, 3

• Amphotericin B: Generally not recommended as first-line therapy due to toxicity and potential resistance of Aureobasidium pullulans 4, 3

Duration of Therapy

• Minimum treatment duration of 6 months is recommended 2
• Treatment may need to be prolonged based on clinical response 2
• Continue therapy until clinical and radiographic abnormalities are resolving 2

Monitoring Response

• Regular follow-up visits to assess clinical response
• Monitor for adverse effects of antifungal therapy
• For patients with significant improvement, follow-up intervals can range from 1-3 months 2

Surgical Considerations

• Surgical debridement may be necessary for localized infections 1
• Vacuum-assisted closure along with surgical drainage may contribute to positive outcomes in certain cases 1

Special Considerations

• In immunocompromised patients, recovery of immune function is critical for treatment success 3
• Reduction of immunosuppressive therapy should be considered when possible 3
• Antifungal susceptibility testing should be performed in cases of treatment failure 3

Potential Complications and Management

• Monitor for drug-drug interactions, particularly with azole antifungals
• Assess liver function regularly during treatment
• Adjust dosing based on renal function, particularly if using amphotericin B formulations

Aureobasidium pullulans is a black yeast-like dematiaceous fungus that can cause opportunistic infections, particularly in immunocompromised hosts. While most infections occur through traumatic inoculation, disseminated infections can occur in immunocompromised individuals 1. Early and appropriate antifungal therapy with voriconazole, along with addressing any underlying immunosuppression, offers the best chance for successful treatment.