Cryptococcal infection in non-HIV immunosuppressed patients – Three case reports in a nephrology setting
An 18 year-old male with unremarkable history until July 2011 (day – 173), was diagnosed with SLE due to anemia, thrombocytopenia, malar rash, and positive anti-nuclear (ANA) and double-strand DNA antibodies (dsDNA). He was prescribed oral prednisone, but failed to comply with. On December 2011 (day – 67) presented to the emergency department with nephritic syndrome. Kidney biopsy revealed a class IV lupus nephritis. He was prescribed high dose methylprednisolone (total 1.5 g) followed by oral prednisone (1 mg/kg), along with twice monthly administrations of intravenous (IV) 500 mg of cyclophosphamide (total 3 doses). Patient was discharged on the 08th of January 2012 (day – 42).\nSix weeks later patient presented to the emergency department (day – 0) due to fever (39 °C) and diarrhea. No other symptoms were reported. Physical examination was unremarkable. Analysis revealed normal leukocyte count, C-RP 70 mg/dL. Chest X-ray revealed no suspicious images. Empirical prescription with ciprofloxacin to an infectious diarrhea was performed and was admitted to the ward. Pneumonia was diagnosed on day 2 due to hypoxemic respiratory failure and a lower right lung condensation on the X-ray. Antibiotherapy spectrum was broadened to meropenem.\nC. neoformans was isolated on blood cultures retrieved at admission (day – 6). Lumbar puncture presented an opening pressure of 26 cm/H2O. Though clear and colorless, CSF fluid was India-ink and culture positive for C. neoformans. Immunosuppression was reduced and iposomal amphotericin B (1 mg/kg per day, IV) plus flucytosine (100 mg/Kg per day, IV) was prescribed. CSF fluid collected on day 28 was sterile and India-ink negative. Patient presented good clinical outcome and was discharged on day 41 prescribed with fluconazole (200 mg per day, oral) for 12 months.