Verruconis gallopava: an isavuconazonium foe.

Background: Verruconis gallopava is a dematiaceous and environmental commensal that rarely causes infection in humans. Human infections are typically observed in immunocompromised individuals. Clinical presentations range from localized infectious (skin and lung) to disseminated disease with a predilection for the central nervous system. Currently, no standardized guidelines exist for the treatment of V. gallopava. Most mold-active triazoles, except isavuconazole, have demonstrated in vitro antifungal activity against this pathogen. Case Summary: We present a case of an immunocompromised male who underwent heart transplantation with subsequent syndrome of chronic pneumonia. Imaging suggested an atypical pulmonary process prompting empiric initiation of isavuconazonium. Despite treatment, the patient's condition worsened, and fungal culture from sputum and bronchoalveolar lavage both grew V. gallopava. His symptoms persisted, and he was transitioned to liposomal amphotericin B and eventually oral posaconazole (POS) with clinical and radiographic resolution of his presenting syndrome. Conclusion: This case highlights the limited experience and clinical failure of isavuconazonium as empiric therapy for V. gallopava. Transitioning to POS led to clinical improvement, suggesting its potential as a treatment option. Further experience is needed to establish optimal therapeutic strategies for this rare but serious infection.