Disseminated Cryptococcus disease occurs in patients with defective T-cell immunity.
Cryptococcal meningitis following autologous stem cell transplant (SCT) has been described previously in only 1 patient, 4 months post SCT and while off antifungal prophylaxis. We present a unique case of Cryptococcus
meningitis pre-engraftment after autologous SCT, while the patient was receiving
fluconazole prophylaxis. A 41-year-old man with
non-Hodgkin's lymphoma underwent autologous SCT. Post-transplant prophylaxis consisted of
fluconazole 400 mg daily,
levofloxacin 500 mg daily, and
acyclovir 800 mg twice daily. On day 9 post transplant, he developed
fever and
headache. Peripheral white blood cell count (WBC) was 700/μL. Magnetic resonance imaging of the brain showed lesions consistent with
meningoencephalitis. Cerebrospinal fluid (CSF) analysis revealed a WBC of 39 with 77% lymphocytes,
protein 63,
glucose 38, CSF pressure 20.5 cmH2 O, and a positive cryptococcal
antigen. CSF culture confirmed Cryptococcus neoformans. The patient was treated with
liposomal amphotericin B 5 mg/kg intravenously daily, and
flucytosine 37.5 mg/kg orally every 6 h. He was switched to
fluconazole 400 mg daily after 3 weeks of
amphotericin therapy, with sterilization of the CSF with negative CSFCryptococcus
antigen and negative CSF culture. Review of the literature revealed 9 cases of cryptococcal disease in recipients of SCT. Median time of onset was 64 days post transplant. Only 3
meningitis cases were described; 2 of them after allogeneic SCT. Fungal prophylaxis with
fluconazole post autologous SCT is recommended at least through engraftment, and for up to 100 days in high-risk patients. A high index of suspicion is needed to diagnose and treat
opportunistic infections, especially in the face of immunosuppression and despite adequate prophylaxis.
Infection is usually fatal without treatment, thus prompt diagnosis and
therapy might be life saving.