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Lack of efficacy: case report A 53-year-old man exhibited lack of efficacy during treatment with amphotericin B and flucytosine for Cryptococcus neoformans infection. The man, who had nephropathy status post kidney transplant, diabetes and end stage renal disease secondary to HIV, was referred for 5 day history of shortness of breath, fevers, chills, subjective weight loss and productive cough. Upon vitals, he was found tachycardic, hypotensive and tachypnoeic. Physical examination was remarkable for hypoactive bowel sounds, decreased percussion at the bases and coarse breath sounds bilaterally. Labs showed leukocytosis, microcytic anaemia, hypernatraemia, acute kidney injury and lactic acidosis. Arterial blood gas showed a metabolic acidosis and CD4 count of 127. Chest CT was notable for diffuse ground glass and hazy opacities congruous with an interstitial pneumonic process. He developed hypoxic respiratory failure secondary to acute respiratory distress syndrome, and was intubated. Bronchoscopic bronchoalveolar lavage was found to be positive for Cryptococcus neoformans with positive serum antigen. He was initiated on antifungal therapy with IV flucytosine and amphotericin B [dosages not stated]. On the fourth day of admission, due to worsening hypoxia in spite of maximal ventilator settings, it was decided to cannulate for extracorporeal membrane oxygenation (ECMO) support. On day 3 of ECMO support, he died despite maximal efforts [immediate cause of death not stated]. Mody M, et al. Cryptococcus: The ultimate mimicker. American Journal of Respiratory and Critical Care Medicine 199: No. 9, May 2019. Available from: URL: https:// 803447350 www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2019.199.1_MeetingAbstracts.A6621 [abstract]

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Reactions 18 Jan 2020 No. 1787