Favorable Evolution of Cryptococcal Meningitis in the Context of Flucytosine Resistance

Exp Clin Transplant. 2018 Feb;16(1):110-113. doi: 10.6002/ect.2015.0217. Epub 2016 Apr 26.

Abstract

Cryptococcal meningitis is a critical illness affecting 0.2% to 5% solid-organ transplant recipients with a 40% to 50% mortality. We report the case of a 48-year-old lung transplant recipient, who, 15 months after a right lung graft, kept parakeets and developed meningitis due to Cryptococcus neoformans. Immunosuppressive treatment was based on a quadruple sequential immunosuppressive therapy that included induction therapy with thymoglobulin, followed by corticosteroids, calcineurin inhibitors, and mycophenolate mofetil. Antifungal susceptibility testing of Cryptococcus neoformans showed resistance to flucytosine and intermediate sensitivity to fluconazole. Initial treatment adhered to international guidelines; however, the patient could not tolerate an effective double-antifungal therapy during the first 2 months of treatment. Despite this delayed treatment for an aggressive infection in an immunocompromised patient, the patient survived without relapse and received maintenance treatment with fluconazole during the course of 3 years. Administration of calcineurin inhibitors as immunosuppressive treatment may partly explain this outcome, as this therapeutic class is known to protect from severe forms of cryptococcal meningitis.

Publication types

  • Case Reports

MeSH terms

  • Antifungal Agents / therapeutic use*
  • Cryptococcus neoformans / drug effects*
  • Cryptococcus neoformans / immunology
  • Cryptococcus neoformans / pathogenicity
  • Drug Resistance, Fungal*
  • Drug Substitution
  • Female
  • Flucytosine / therapeutic use*
  • Humans
  • Immunocompromised Host
  • Immunosuppressive Agents / adverse effects
  • Lung Transplantation / adverse effects*
  • Meningitis, Cryptococcal / diagnosis
  • Meningitis, Cryptococcal / drug therapy*
  • Meningitis, Cryptococcal / immunology
  • Meningitis, Cryptococcal / microbiology
  • Microbial Sensitivity Tests
  • Middle Aged
  • Opportunistic Infections / diagnosis
  • Opportunistic Infections / drug therapy*
  • Opportunistic Infections / immunology
  • Opportunistic Infections / microbiology
  • Risk Factors
  • Treatment Outcome

Substances

  • Antifungal Agents
  • Immunosuppressive Agents
  • Flucytosine