Isavuconazole as an adjunctive antifungal in the multimodal management of pulmonary aspergilloma and chronic cavitary pulmonary aspergillosis: a single-centre case series

Abstract

Symptomatic pulmonary aspergilloma and chronic cavitary pulmonary aspergillosis (CCPA) are typically managed with surgical resection or prolonged triazole therapy, but many patients are poor surgical candidates, and many cannot tolerate voriconazole. Our centre has previously described bronchoscopic debridement combined with antifungal therapy as a minimally invasive alternative for patients with accessible intracavitary fungal balls. Isavuconazole, a newer triazole with a more favourable adverse-event and drug–drug interaction profile, has not been well characterised in this setting. We performed a retrospective single-centre review of nine adults with pulmonary aspergilloma or CCPA referred to our interventional pulmonology service who received isavuconazole between September 2022 and September 2025. Of these, six underwent attempted bronchoscopic debridement (four successful, two with limited or unsuccessful access), one required surgical resection after bronchoscopy failed, one was managed medically because the cavity was inaccessible, and one declined further procedure. Three patients had previously received voriconazole; two were switched to isavuconazole because of intolerance and one was re-treated with isavuconazole at recurrence. One patient developed isavuconazole-associated drug-induced liver injury requiring discontinuation. Three patients died during follow-up: two from causes unrelated to aspergillosis (acute coronary event during dialysis; progression of metastatic colorectal cancer) and one from refractory hemoptysis after isavuconazole was stopped for hepatotoxicity. In this small heterogeneous cohort, isavuconazole appeared well tolerated and was a feasible alternative to voriconazole when prolonged adjunctive therapy was required alongside bronchoscopic or medical management of pulmonary aspergilloma and CCPA. Larger comparative studies are needed to define its place in multimodal protocols.