title: Voriconazole use and pharmacokinetics in combination with interferon-gamma for refractory cryptococcal meningitis in a patient receiving low-dose ritonavir.
abstract: We present a case of relapsing cryptococcal meningitis unresponsive to standard therapy. Voriconazole induction, including the utilization of voriconazole therapeutic drug monitoring in both serum and CSF, with transition to voriconazole plus interferon-gamma (IFN-gamma) was successfully used in a patient receiving antiretroviral therapy with abacavir/lamivudine and lopinavir/ritonavir. Initial voriconazole levels at standard doses of 4 mg/kg twice daily intravenously were low when co-administered with lopinavir/ritonavir but increased to recommended therapeutic levels with an increase of the voriconazole dose to 7 mg/kg twice daily. This case highlights the utility of voriconazole therapeutic drug monitoring when prescribed concurrently with a ritonavir boosted protease inhibitor and the potential role of combination therapy with IFN-G for refractory cryptococcal meningitis.
authors.affiliation: Department of Internal Medicine, Division of General Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA. nierenberg@uthscsa.edu
authors.forename: Natalie E
authors.initials: NE
authors.lastname: Nierenberg
authors.forename: George R
authors.initials: GR
authors.lastname: Thompson
authors.forename: James S
authors.initials: JS
authors.lastname: Lewis
authors.forename: Brian K
authors.initials: BK
authors.lastname: Hogan
authors.forename: Thomas F
authors.initials: TF
authors.lastname: Patterson
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use; D000935:Antifungal Agents / Q000008:administration & dosage / Q000493:pharmacokinetics* / Q000627:therapeutic use; D002555:Cerebrospinal Fluid / Q000737:chemistry; D015224:Dideoxynucleosides / Q000627:therapeutic use; D016903:Drug Monitoring; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy; D006801:Humans; D007371:Interferon-gamma / Q000493:pharmacokinetics* / Q000627:therapeutic use; D019259:Lamivudine / Q000627:therapeutic use; D008297:Male; D016919:Meningitis, Cryptococcal / Q000188:drug therapy*; D011743:Pyrimidines / Q000008:administration & dosage / Q000493:pharmacokinetics* / Q000627:therapeutic use; D019438:Ritonavir / Q000627:therapeutic use; D044967:Serum / Q000737:chemistry; D014230:Triazoles / Q000008:administration & dosage / Q000493:pharmacokinetics* / Q000627:therapeutic use; D065819:Voriconazole; D055815:Young Adult; D000099227:Abacavir
chemical_list: D019380:Anti-HIV Agents; D000935:Antifungal Agents; D015224:Dideoxynucleosides; D007371:Interferon-gamma; D019259:Lamivudine; D011743:Pyrimidines; D019438:Ritonavir; D014230:Triazoles; D065819:Voriconazole; D000099227:Abacavir