Reactions 1444 - 23 Mar 2013

SFluconazole/prednisolone/triamcinolone

Disseminated cryptococcosis and immunereconstitution inflammatory syndrome: case report

A 34-year-old man developed disseminated cryptococcosisduring treatment with prednisolone and triamcinolone fornephrotic syndrome. He was treated with fluconazole but hiscondition suddenly deteriorated possibly due to immunereconstitution inflammatory syndrome (IRIS) and he died [notall routes and durations of treatments to reactions onsetsstated].

The man had been diagnosed with nephrotic syndrome1 year prior to presentation and began treatment withprednisolone 60mg daily and furosemide. His proteinuria andlower extremity oedema resolved but his oedema recurred3 months later due to a gradual dose reduction. He wasadministered triamcinolone 48mg daily. Before long, hepresented with high fever, severe pain and skin ulceration ofhis lower extremities. His lesions enlarged and his feverpersisted. He was hospitalised and examination revealedmassive superficial necrotic ulceration on both inner thighswith overlying erythema. He also had several reddishindurations of his forearms. He was treated with empiricalantibiotics for assumed bacterial cellulitis. He was also treatedwith gammaglobulin and he still received his prednisolone60mg daily for nephrotic syndrome. His cutaneous lesions hadslightly reduced 3 days later but his high fever persisted. Achest x-ray showed ground-glass opacity changes in his lungs.A blood culture showed coagulase negative staphylococci.Linezolid and caspofungin were administered but he showedlittle response and developed blurred consciousness, delirium,and hypoxaemia. He was transferred to an ICU. Biopsy testsrevealed Cryptococcus neoformans on day 4 of his admission.Microbiological cultures of blood, sputum, and the biopsyspecimen confirmed the C. neoformans infection. He becameunconscious.

The man received IV fluconazole 400mg daily and empiricalantibiotic therapy was continued. He suddenly developedsigns of acute respiratory failure on the sixth day. He hadintractable hypoxaemia and underwent mechanicalventilation. Acute heart failure occurred, his blood pressurewas low, and he had oliguria. He died on day 8 of hisadmission [cause of death not clearly stated].

Author comment: "[W]ith an increasing number ofsteroid-dependent individuals as our patient in the lastdecade, the prevalence rate of cryptococcosis is continuouslyrising. . . [T]he patients’ suddenly deteriorated condition aftertwo day’s antifungal therapy reminded that immunereconstitution inflammatory syndrome (IRIS) might also havecontributed to his death."Ni W, et al. Disseminated cryptococcosis initially presenting as cellulitis in apatient suffering from nephrotic syndrome. BMC Nephrology 14: [4 pages], No.20, Jan 2013. Available from: URL: http://dx.doi.org/10.1186/1471-2369-14-20 -China 803084623

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Reactions 23 Mar 2013 No. 14440114-9954/10/1444-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved