• PDF / 171,470 Bytes
• 1 Pages / 595.245 x 841.846 pts (A4) Page_size
• 98 Downloads / 183 Views

DOWNLOAD

REPORT

---

1 S

Disseminated cryptococcosis and lack of efficacy: case report A 73-year-old man developed disseminated cryptococcosis during treatment with methylprednisolone and exhibited lack of efficacy during treatment with amphotericin B liposomal, fluconazole, flucytosine and plasma [not all routes and dosages stated; duration of treatment to reaction onset not stated]. The man was referred to a hospital with a 7-day history of chills and high-grade fever. He also had a sore throat, dyspnoea on exertion, generalised weakness and weight loss. His medical history was significant for a partial gastrectomy due to stomach cancer, hypertension, diabetes mellitus and retroperitoneal fibrosis with right ureter extraluminal stenosis, which was corrected with a unilateral pigtail insertion. After a diagnosis of retroperitoneal fibrosis, he had been receiving 32 mg/day methylprednisolone for the previous month. His lung CT scan identified bilateral pleural effusions, ground-glass opacities on the right upper lobe and the existence of a solitary pulmonary nodule or mass with cavitation in the same lobe, resembling a fungal ball. The abdominal CT scan showed an irregular gastrectomy stump with the presence of ascites and evidence of malignant disease. Blood cultures drawn at the time of admission were found to be positive for a yeast, which was subsequently identified as Cryptococcus neoformans. As the C. neoformans isolate was susceptible to posaconazole, voriconazole, flucytosine, amphotericin B, itraconazole and fluconazole, the man was treated with a loading dose of 800mg of fluconazole and an IV maintenance dose of 400 mg/day, along with flucytosine, linezolid, metronidazole and ceftolozane/tazobactam. Within several days of treatment, he became afebrile with dramatic improvement in medical condition. C. neoformans was also isolated from his sputum and pleural fluid. The pleural fluid showed the presence of cancer cells on cytology examination. Additionally, when examined by an ear, nose, and throat specialist, he showed evidence of fungal stomatitis, laryngitis and pharyngitis. Owing to the dissemination of his cryptococcal disease (disseminated cryptococcosis), on day 40 of his admission, 4mg of amphotericin B liposomal/kg of body weight/day was added to the antibiotic regime. On day 43 of admission, he became disoriented with disturbances of consciousness. He underwent a lumbar puncture. Examination of the CSF revealed the appearance of elevated protein and yeasts noted on India ink examination. The results of cryptococcal latex agglutination test, herpes simplex virus 1 (HSV-1) test and a PCR test for C. neoformans were found to be positive. He was maintained on his combination antifungal therapy regimen, with aciclovir added for the treatment of HSV-1 infection. His cardiopulmonary condition abruptly worsened, necessitating pulmonary intubation and transfer to the ICU. He needed continual mechanical respiratory support and subsequently became haemodynamically unstable and anuric. Development of coagulation disturbances and