title: Favorable Evolution of Cryptococcal Meningitis in the Context of Flucytosine Resistance.
abstract: Cryptococcal meningitis is a critical illness affecting 0.2% to 5% solid-organ transplant recipients with a 40% to 50% mortality. We report the case of a 48-year-old lung transplant recipient, who, 15 months after a right lung graft, kept parakeets and developed meningitis due to Cryptococcus neoformans. Immunosuppressive treatment was based on a quadruple sequential immunosuppressive therapy that included induction therapy with thymoglobulin, followed by corticosteroids, calcineurin inhibitors, and mycophenolate mofetil. Antifungal susceptibility testing of Cryptococcus neoformans showed resistance to flucytosine and intermediate sensitivity to fluconazole. Initial treatment adhered to international guidelines; however, the patient could not tolerate an effective double-antifungal therapy during the first 2 months of treatment. Despite this delayed treatment for an aggressive infection in an immunocompromised patient, the patient survived without relapse and received maintenance treatment with fluconazole during the course of 3 years. Administration of calcineurin inhibitors as immunosuppressive treatment may partly explain this outcome, as this therapeutic class is known to protect from severe forms of cryptococcal meningitis.
authors.affiliation: From the Department of Biochemistry, Molecular and Cellular Biology, Georgetown University Medical Center, Washington DC 20007, USA.
authors.forename: Johanna
authors.initials: J
authors.lastname: Claustre
authors.forename: Jean-Paul
authors.initials: JP
authors.lastname: Brion
authors.forename: Sébastien
authors.initials: S
authors.lastname: Quétant
authors.forename: Pierrick
authors.initials: P
authors.lastname: Bedouch
authors.forename: Christophe
authors.initials: C
authors.lastname: Pison
authors.forename: Boubou
authors.initials: B
authors.lastname: Camara
mesh_terms: D000935:Antifungal Agents / Q000627:therapeutic use*; D003455:Cryptococcus neoformans / Q000187:drug effects* / Q000276:immunology / Q000472:pathogenicity; D025141:Drug Resistance, Fungal; D057915:Drug Substitution; D005260:Female; D005437:Flucytosine / Q000627:therapeutic use*; D006801:Humans; D016867:Immunocompromised Host; D007166:Immunosuppressive Agents / Q000009:adverse effects; D016040:Lung Transplantation / Q000009:adverse effects*; D016919:Meningitis, Cryptococcal / Q000175:diagnosis / Q000188:drug therapy* / Q000276:immunology / Q000382:microbiology; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D009894:Opportunistic Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000276:immunology / Q000382:microbiology; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D000935:Antifungal Agents; D007166:Immunosuppressive Agents; D005437:Flucytosine