final program.qxd - Parallels Plesk Panel

PP 3.28
Successful treatment of AIDS-associated Cryptococcus neoformans meningitis,
apparently prompting the emergence of amphotericin B-resistant Cryptococcus
laurentii central nervous system infection
Roberto Manfredi
Roberto Manfredi, Ciro Fulgaro
Introduction
Less than 20 episodes of Cryptococcus laurentii infection were described until now in the
international literature.
Case report
A 34-year-old male with HIV infection since 8 years, was lost to follow-up until his hospital
admission, due to severe fever and headache. A moderately advanced infection was
shown by a CD4+ lymphocyte count of 151 cells/µL, and a viral load of 122,861 HIV-RNA
copies/mL. Cerebrospinal fluid (CSF) culture and capsular antigen assays confirmed a
Cryptococcus neoformans meningitis, with full susceptibility to all polyenes and azoles.
Liposomal amphotericin B (lAB) was started at 3 mg/Kg/day with immediate benefit, but
our p self-discharged after only 12 days, and denied further monitoring, until a subsequent
hospitalization occurred 14 weeks after, owing to the same signs-symptoms.
C. neoformans was isolated again from both CSF and blood, with positive antigen search
in both CSF and serum, and a persisting sensitivity to all antifungals. Negative CSF-blood
microscopy-cultures were achieved after 28 days of lAB administration associated with
flucytosine. Six weeks after patient's discharge, a novel relapse occurred despite HAART
initiation and a weekly maintenance with lAB. At that time, the CSF study disclosed an
unexpected, isolated C. laurentiii, which proved resistant to both lAB and flucytosine, but
sensitive to all azoles. Concurrently, all mycological searches for C. neoformans infection
tested negative. High dose fluconazole started, and HAART continued:after 43 days,
negative C. laurentii microscopic-culture CSF assays were obtained, and no further
episodes of relapses of cryptococcosis occurred during the subsequent 65-month followup,
also thanks to a restored CD4+ count (above 400 cells/µL).
POSTERS
Discussion
Clinicians facing HIV-infected p, should consider that cryptococcosis may still occur,
although a dual, subsequent infection by C. neoformans and C. laurentii is a very
unfrequent event. The eradication of C. neoformans does not guarantee that another
Cryptococcus spp. could occur subsequently. Moreover, the polysaccharide antigen assay
is not predictable for C. laurentii, and the susceptibility studies are mandatory for
C. laurentii treatment, due to its unpredictable antifungal sensitivity profile. Further studies
are needed to assess whether antimycotic treatment and prophylaxis against
C. neoformans may help to select resistant C. laurentii strains.
“ Focusing FIRST on PEOPLE “ 169 w w w . i s h e i d . c o m