Immunosuppressants
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Immunosuppressants Cryptococcus neoformans meningitis: case report.
A 48-year-old man developed Cryptococcus neoformans meningitis during treatment with dexamethasone, rituximab, etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, gemcitabine, cisplatin, alemtuzumab, busulfan, fludarabine, tacrolimus and methotrexate [not all routes and dosages stated]. The man presented with a history of dull frontal headache and low grade fever since 3 days. He rated headache severity as 5 on a scale of 0 to 10. He reported malaise, myalgias and chills with other symptoms. Two years before, he was diagnosed with haemophagocytic lymphohistiocytosis (HLH). He was treated with dexamethasone, etoposide, rituximab, vincristine, prednisone, doxorubicin and cyclophosphamide. After 8 months of initiation of the treatment, he developed Epstein-Barr virus (EBV) positive diffuse large B-cell lymphoma. Therefore, he received 5 cycles of rituximab, doxorubicin, cyclophosphamide, vincristine and prednisone. Subsequently, he received a cycle of rituximab, gemcitabine, cisplatin and dexamethasone for an isolated residual atypical B lymphocyte. Additionally, he was treated with alemtuzumab. After 2 weeks, he underwent reduced intensity allogeneic haematopoietic stem cell transplant (HSCT). His conditioning regimen for the transplant included IV busulfan and fludarabine. Additionally, prophylaxis treatment against graft versus host disease (GVHD) included methotrexate and tacrolimus 3mg twice daily. After the transplant, engraftment was achieved but stage 3 skin GVHD and stage 1 liver GVHD developed. After prednisone 2 mg/kg daily treatment, the GVHD resolved rapidly. He presented after 3 months of the transplant and his dose of prednisone was tapered to 40mg daily. His medical history included membranous nephropathy, mixed connective tissue disease, hypertension and gastrooesophageal reflux disease. On current presentation, he was on various medications includig omeprazole, lisinopril, aciclovir [acyclovir] and cotrimoxazole [trimethoprim-sulfamethoxazole]. He was then admitted and underwent extensive investigations including CSF analysis. Pancytopenia was noted. He was empirically treated with IV cefepime in addition to prophylactic cotrimoxazole and aciclovir. The CSF findings were consistent with an aseptic meningitis. On day 6 of admission, the CSF evaluation returned positive for cryptococcus antigen. Based on further investigations, a diagnosis of Cryptococcus neoformans related meningitis was made. There were no signs of lymphoma. The man was started on 2 weeks induction treatment with flucytosine, amphotericin-B liposomal [liposomal amphotericin-B] and fluconazole 600mg daily. After 3 days of initiation of the treatment, his fever improved, but headache persisted. A lumbar puncture was performed with opening intracranial pressure of 35cm of water (increased intracranial pressure) and removal of CSF. It was thought that the increased intracranial pressure led to persistent headache secondary to amphotericin-B liposomal
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