Cryptococcal infection in non-HIV immunosuppressed patients – Three case reports in a nephrology setting
A 34 year-old male with chronic renal failure due to renal malformation, was admitted due to persistent headaches. Patient was diagnosed with bilateral renal atrophy at the age of 3. He was on hemodialysis since 1998 (day – 4783) and submitted to deceased-donor renal transplant in April 2001 (day – 3780). Immunosuppressive therapy consisted of cyclosporine A (CsA) and mycophenolate mofetil (MMF), with posterior conversion to sirolimus. High dose methylprednisolone (MP), plasmapheresis, monthly high-dose immunoglobulin infusions, and rituximab were administered due to acute humoral rejection in April 2010 (day – 548).\nOn November 2011 (day – 0) he was presented to the emergency department with a 5 day frontal headache, nausea and vomiting, photo- and phonophobia. No other symptoms were reported, namely fever. Physical examination was unremarkable. Hematologic and biochemical analysis demonstrated normal white blood cells count, no anemia nor thrombocytopenia, and a normal C-Reactive Protein (C-RP) level. Urinary sediment was bland. Chest X-ray, abdominal and graft ultrasounds were normal. Thoracic CT revealed condensation on the upper lobe of the left lung. Cerebral MRI presented asymmetric cortical lesions, with hyperintensity on T2-weighted and hipointensity on T1-weighted images.\nCerebral spinal fluid (CSF) analysis revealed 138 white blood cells (137 lymphocytes), glucose 0.69 g/L, and proteins 0.69 g/L. CSF was India-ink and culture positive for C. neoformans, and polymerase chain reaction (PCR)-positive for cytomegalovirus (CMV).\nA meningoencephalitis to C. neoformans concomitant with CMV infection was assumed. On day 2 treatment with liposomal amphotericin B associated to fluconazole was initiated, along with valganciclovir and anti-CMV immunoglobulins. Lumbar puncture repeated on day 15 revealed a CSF negative for both agents. Transition to fluconazole (400 mg per day, oral) for 12 months and valganciclovir (450 mg every other day) for 6 months was performed. Sustained clinical response was achieved.