A Case Report of Antifungal-Resistant Cryptococcal Meningitis in a Patient with Kidney Transplant

Document Type : Case Report

Authors

1 Student of Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran

2 Associate Professor, Department of Infectious Diseases, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran

3 Professor, Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran

4 Associate Professor, Department of Medical Parasitology and Mycology, School of Medicine AND Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Abstract

Background: Cryptococcal meningitis is a chronic fungal meningitis caused by Cryptococcus neoformans or Cryptococcus gattii. Acquired immunodeficiency syndrome (AIDS) and the use of immunosuppressive drugs are the main underlying factors of the disease. In this case report, we present a patient with cryptococcal meningitis who left the hospital after three months of unsuccessful monitoring and treatment.Case Report: The patient was a 20-year-old woman who underwent a kidney transplant three years before, and was referred to Alzahra hospital in Isfahan, Iran, with generalized headache, diplopia, photophobia, phonophobia, weight loss, vomiting, and Kernig's sign. By isolating the yeast from the cerebrospinal fluid, fluconazole was prescribed for her. After 18 days, the antifungal drug regimen was changed to amphotericin B deoxycholate. Due to no improvement in symptoms, the patient left the hospital after three months with personal consent. Molecular identification of the fungus was performed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. For this purpose, ITS1-5.8S-ITS2 region was amplified and cut with HpaII restriction enzyme and Cryptococcus neoformans was identified as the causative agent of infection using the digested band pattern (127 and 428 bp).Conclusion: Patients taking immunosuppressive drugs are at risk for invasive fungal infections. Due to the emergence of resistant clinical isolates to antifungal agents, evaluation of drug susceptibility of fungi in specialized laboratories in parallel with clinical treatment of patients is recommended to prevent mortality and impose side effects of antifungal drugs on these patients.

Keywords


  1. Sloan DJ, Parris V. Cryptococcal meningitis: Epidemiology and therapeutic options. Clin Epidemiol 2014; 6: 169-82.
  2. Park BJ, Wannemuehler KA, Marston BJ, Govender N, Pappas PG, Chiller TM. Estimation of the current global burden of cryptococcal meningitis among persons living with HIV/AIDS. AIDS 2009; 23(4): 525-30.
  3. Pappas PG, Perfect JR, Cloud GA, Larsen RA, Pankey GA, Lancaster DJ, et al. Cryptococcosis in human immunodeficiency virus-negative patients in the era of effective azole therapy. Clin Infect Dis 2001; 33(5): 690-9.
  4. Mohammadi R, Mirhendi H, Rezaei-Matehkolaei A, Ghahri M, Shidfar MR, Jalalizand N, et al. Molecular identification and distribution profile of Candida species isolated from Iranian patients. Med Mycol 2013; 51(6): 657-63.
  5. Husain S, Wagener MM, Singh N. Cryptococcus neoformans infection in organ transplant recipients: variables influencing clinical characteristics and outcome. Emerg Infect Dis 2001; 7(3): 375-81.
  6. Pan WG, Chen BC, Li YF, Wu RX, Wang CH. An unusual case of reactivated latent pulmonary cryptococcal infection in a patient after short-term steroid and azathioprine therapy: a case report. BMC Pulm Med 2021; 21(1): 76.
  7. Neofytos D, Fishman JA, Horn D, Anaissie E, Chang CH, Olyaei A, et al. Epidemiology and outcome of invasive fungal infections in solid organ transplant recipients. Transpl Infect Dis 2010; 12(3): 220-9.
  8. Singh N, Huprikar S, Burdette SD, Morris MI, Blair JE, Wheat LJ. Donor-derived fungal infections in organ transplant recipients: guidelines of the American Society of Transplantation, infectious diseases community of practice. Am J Transplant 2012; 12(9): 2414-28.
  9. Diaz JH. The Disease Ecology, Epidemiology, Clinical Manifestations, and Management of Emerging Cryptococcus gattii Complex Infections. Wilderness Environ Med 2020; 31(1): 101-9.
  10. Nsenga L, Kajjimu J, Olum R, Ninsiima S, Kyazze AP, Ssekamatte P, et al. Cryptococcosis complicating diabetes mellitus: A scoping review. Ther Adv Infect Dis 2021; 8: 20499361211014769.
  11. Hakim JG, Gangaidzo IT, Heyderman RS, Mielke J, Mushangi E, Taziwa A, et al. Impact of HIV infection on meningitis in Harare, Zimbabwe: A prospective study of 406 predominantly adult patients. AIDS 2000; 14(10): 1401-7.
  12. Kabanda T, Siedner MJ, Klausner JD, Muzoora C, Boulware DR. Point-of-care diagnosis and prognostication of cryptococcal meningitis with the cryptococcal antigen lateral flow assay on cerebrospinal fluid. Clin Infect Dis 2014; 58(1): 113-6.
  13. Perfect JR, Dismukes WE, Dromer F, Goldman DL, Graybill JR, Hamill RJ, et al. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis 2010; 50(3): 291-322.
  14. Singh N, Lortholary O, Alexander BD, Gupta KL, John GT, Pursell K, et al. An immune reconstitution syndrome-like illness associated with Cryptococcus neoformans infection in organ transplant recipients. Clin Infect Dis 2005; 40(12): 1756-61.
  15. Singh N, Perfect JR. Immune reconstitution syndrome associated with opportunistic mycoses. Lancet Infect Dis 2007; 7(6): 395-401.