Fatal cerebral scedosporiosis in a liver transplant recipient: Diagnostic pitfalls and antifungal resistance

Scedosporium boydii causes lethal central nervous system (CNS) disease in transplant recipients and is intrinsically resistant to amphotericin B. A 54-year-old living-donor liver transplant recipient re-admitted (Day 0) with fever and diarrhoea, rapidly deteriorated neurologically, and developed ventriculitis with hydrocephalus. Liquid culture yielded a floating “fungal ball” by Day +8. Microscopy suggested Scedosporium/Lomentospora spp, MALDI-TOF, and ITS sequencing confirmed S. boydii. Amphotericin B MIC was 4.0 μg/mL; voriconazole MIC 0.03 μg/mL. Despite IV voriconazole (with intraventricular caspofungin) and neurosurgery, the patient died of complications. Early molecular identification and prompt switch from amphotericin B to azole-based therapy are critical in post-transplant CNS scedosporiosis.