[Cerebral cryptococcosis and immune reconstitution inflammatory syndrome. Case report]

Area of Science:

• Infectious Diseases
• Neurology
• Pharmacology

Background:

• Central nervous system (CNS) infections in patients with Acquired Immunodeficiency Syndrome (AIDS) require effective antifungal therapy.
• Cryptococcus neoformans is a significant opportunistic pathogen in immunocompromised individuals.

Observation:

• A 45-year-old male with AIDS presented with Cryptococcus neoformans CNS infection.
• Initial treatment with amphotericin B deoxycholate was switched to voriconazole due to toxicity.
• Standard voriconazole dosing resulted in suboptimal plasma levels (0.7 μg/mL), necessitating a dose increase to 4.5 μg/mL.

Findings:

• The patient achieved favorable clinical evolution after dose adjustment and initiation of non-interacting antiretroviral therapy.
• Three months post-discharge, the patient presented with seizures and new sub-cortical nodules on MRI.
• These findings, after excluding other causes and confirming fungal eradication, were consistent with an immune reconstitution inflammatory syndrome (IRIS) event.

Implications:

• This case highlights the importance of therapeutic drug monitoring for voriconazole in patients with CNS fungal infections.
• It underscores the potential for IRIS development in HIV-infected patients with opportunistic infections during antiretroviral therapy initiation.
• Successful management of voriconazole-related toxicity and subsequent IRIS with steroids suggests a viable treatment approach.