Ciclosporin/prednisone

Abstract

Pulmonary cryptococcosis: case report A 33-year-old man developed pulmonary cryptococcosis during treatment with ciclosporin and prednisone idiopathic membranous nephropathy (IMN) [not all routes stated; time to reaction onset not stated]. The man, who was diagnosed with IMN in May 2008, was admitted to the hospital on 8 February 2018 with deteriorated dyspnoea and weakness for 1 week. He had received prednisone 60 mg/day following the diagnosis of IMN. However, his proteinuria persisted. Hence, he had received tripterygium-glycosides with prednisone 30 mg/day in August 2008. After 6 months of prednisone therapy, he developed bilateral femoral head necrosis. Hence, prednisone was adjusted to oral ciclosporin [Cyclosporin A] 75mg/12 hours. After successful treatment with ciclosporin, the dose of ciclosporin was maintained to 75 mg/day till 1 year later. Over the next few years, he experienced recurred albuminuria for several times. His IMN was stable for about 4 years. However, he received ciclosporin 25mg every 12 hours to control recurrence of IMN. In January 2018, proteinuria relapsed and the dose of ciclosporin was increased to 75mg twice daily. In February 2018 (one month after increased dose of ciclosporin), he exhibited dyspnoea and shortness of breath. Subsequent lung computed tomography (CT) scan showed nodules in the left upper lobe with multiple massive or patchy high-density shadows in the left upper lobe of the lung. In subsequent days, his dyspnoea and shortness of breath deteriorated. Hence, on 8 February 2018, he was admitted to the hospital for further examination (current presentation). The man subsequently started receiving empirical anti-bacterial therapy with piperacillin/tazobactam [piperacillin-tazobactam] for 1 week. Thereafter, a chest CT scan was performed which showed no improvement of the nodules in the left upper lobe. At the same time, his serum cryptococcal antigen test returned positive. Then, he underwent a CT-guided lung biopsy to confirm the diagnosis. The pathologic examination of the tissue biopsy showed multiple round shape organisms. Immunohistochemistry result was compatible with Cryptococcus spp. The fungal culture of the tissue showed Cryptococcus neoformans. Based on the clinical investigations, he was diagnosed with pulmonary cryptococcosis. His cerebrospinal fluid (CSF) for fungus and cryptococcal antigen were all negative. It was concluded that, he had developed pulmonary cryptococcosis secondary to immunosuppressive therapy with ciclosporin and prednisone. As corrective measures, he received antifungal therapy with voriconazole followed by fluconazole. Due to massive proteinuria, his oral ciclosporin therapy was maintained at the dose of 75mg every 12 hours as before hospitalisation. On 1 March 2018, a second chest CT scan was performed which showed a decrease in the size of the nodule (massive or patchy high-density shadows) in the area of the left upper lobe and serum cryptococcal antigen was negative. Additionally, the amount of proteinuria decreased after the initiation of anti-fungal administration and subsequently normalised. On 5 March 2018, he was discharged on fluconazole therapy for 9 months. His chest CT scans in September and December 2018 showed complete remission of the lesion in the left upper lobe. He did not exhibit relapse of pulmonary cryptococcosis during a further outpatient follow-up visit.