Voriconazole-Induced Pancreatitis Despite Therapeutic Trough Concentrations During Treatment of Disseminated Fusariosis in a Hospitalized Patient.

BACKGROUND Invasive fungal infections are a major cause of morbidity and mortality in immunocompromised patients, particularly those with hematologic malignancies. Disseminated fusariosis is a severe fungal infection associated with high mortality and often requires prolonged antifungal therapy. Voriconazole, a triazole antifungal with activity against Fusarium species, is commonly used but is associated with variable pharmacokinetics and potential toxicities. Acute pancreatitis despite therapeutic drug level is a rare adverse effect of voriconazole. CASE REPORT We present the case of a 62-year-old man with relapsed myelodysplastic syndrome progressing to acute myeloid leukemia who developed disseminated Fusarium infection confirmed by skin biopsy and culture. He was initially treated with amphotericin B and isavuconazonium, then transitioned to voriconazole for targeted antifungal therapy. After 18 days of therapy, he developed acute epigastric pain and poor oral intake. Evaluation demonstrated acute pancreatitis based on characteristic abdominal pain, elevated serum lipase, and imaging findings consistent with acute interstitial edematous pancreatitis. Alternative etiologies were excluded, including gallstones, alcohol use, hypercalcemia, and severe hypertriglyceridemia. Voriconazole was discontinued due to concern for drug-induced pancreatitis despite therapeutic trough levels between 1 and 2.1 mcg/mL, and antifungal therapy was transitioned back to isavuconazonium while continuing amphotericin B. Symptoms improved within 24 hours and resolved completely within 48 hours following drug discontinuation, supporting a probable diagnosis of voriconazole-induced pancreatitis. CONCLUSIONS This case highlights voriconazole-induced pancreatitis as a clinically important adverse event that may occur despite therapeutic drug levels. Early recognition and prompt drug discontinuation can lead to rapid clinical recovery and allow for transition to alternative antifungal therapy.