Lung cryptococcosis in a treated HIV-1-infected patient with suppressed viral load and past disseminated cryptococcosis: relapse or late IRIS?

摘要

Early initiation of combination antiretroviral therapy (cART) in AIDS presenters reduces mortality,1 but seems to worsen survival in cryptococcal meningitis, probably because of immune reconstitution inflammatory syndrome (IRIS), with fatal cerebral complications.2'3 Timing of cART initiation is not clearly defined, ranging from 2 to 10 weeks.4 Strategies aiming at reducing the risk of IRIS are lacking.We report a case of pulmonary and mediastinal lymph node cryptococcosis occurring late after immune reconstitution and fluconazole prophylaxis discontinuation in a patient with previous AIDS-presenting disseminated/meningeal cryptococcosis. A Pakistani man in his mid-forties presented with AIDS and disseminated/meningeal cryptococcosis (CD4 count 16 cells/mm3, plasma HIV-1 RNA 191100 copies/mL and blood and CSF cultures positive for Cryptococcus neoformans). He was treated with a standard amphotericin B course, followed by secondary fluconazole prophylaxis; cART was introduced 1 month later with co-formulated zidovudine/lamivudine and lopinavir/ritonavir, achieving virological suppression and immune restoration (Figure 1). The nucleoside backbone was switched to tenofovir/emtricitabine after 1 month, because of bone marrow toxicity (haemoglobin 8.3 g/dL, white blood cells 1910/mm3 and neutrophils 390/mm3).