Cryptococcosis in an AIDS patient : itraconazole efficacy after
other therapeutic failures
Citation for published version (APA):
Pelloux, H., Lebeau, B., Manquat, G., Leclercq, P. A., Blanc, M., Ambroise-Thomas, P., & Grillot, R. (1993). Cryptococcosis in an AIDS patient : itraconazole efficacy after other therapeutic failures. Journal of Infection, 26(2), 221-222. https://doi.org/10.1016/0163-4453(93)93139-U
DOI:
10.1016/0163-4453(93)93139-U
Document status and date: Published: 01/01/1993
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Journal of Infection (1993) z6, 221-232
L e t t e r s t o t h e E d i t o r
Cryptococcosis in an A I D S patient: Itraconazole efficacy after other therapeutic failures
Accepted for publication 27 April 1992
Sir,
Cryptococcus neoformans, an ubiquitous soil yeast, causes neurological a n d / o r
disseminated mycotic invasion and is the fourth most c o m m o n infection in A I D S patients. ~ Conventional treatment of cryptococcosis [amphotericin B (AMB) with flucytosine] is not completely satisfactory in such patients because of persistent i m m u n e defects and frequent toxicity of these antifungal drugs. F o r these reasons fluconazole (FCZ) is often prescribed as initial therapy but it is effective in only about 40 % cases. 2 Itraconazole ( I T Z ) , a recently introduced triazole, has been successfully administered after failure of the other drugs.
We report the case of a 3o-year-old H I V - p o s i t i v e man, who was hospitalised because of sudden coma and developed a left VI nerve paralysis a few days later. Cryptococcal meningitis was diagnosed when C. neoformans was isolated from the C S F and cryptococcal soluble antigen found in high titre in C S F and serum.
Oral F C Z (400 rag/day) was prescribed with transient i m p r o v e m e n t of con- sciousness and the left VI nerve paralysis. H o w e v e r he then relapsed and developed bradypsychia and obnubilation. At the same time two low density cerebral lesions appeared on C T scan. On day 38 of treatment IV A M B (I mg/kg) was added and the F C Z raised to 800 m g / d a y . On day 55, neurological problems had increased and a further therapeutic change was implemented. Oral I T Z was prescribed in association with A M B for 7 days and then continued alone. In less than a week neurological i m p r o v e m e n t had started and the patient eventually achieved an approximately normal life style. After 9 months of I T Z administration, the patient was tolerating the drug satisfactorily apart from some disturbance of liver function tests (raised transaminase and alkaline phosphatase values) which required reduction of the dose to 200 m g / d a y .
T h e response of our patient to I T Z following the therapeutic failure of F C Z and A M B in high dosage for 55 days, confirms its efficacy. T h e r e are however very few publications concerning I T Z therapy in A I D S cryptococcosisfl -~ Our case showed apparent clinical synergy between A M B and I T Z . In a previous study, I T Z alone had a 40 % complete response rate which rose to 83 % if up to I week of A M B was given before the I T Z .
F r o m a mycological point of view, C S F cultures were negative after 50 days of treatment, but after 7 months, direct examination confirmed the presence of cryptococcus and soluble antigen in the CSF. T h e s e findings did not reflect the clinical situation and justified continued I T Z therapy.
* Service de Parasitologie,
t Clinique Mddicale et des Maladies Infectieuses, C H U A. Michallon, B P 217, 38043 Grenoble Cddex and ~. Service de Mddecine, C H R , B P I I 2 5 , 7 3 o i i Chambdry, France H. Pelloux* B. Lebeau* G. ManquatJf P. LeclercqJf M . Blanc~ P. Ambroise- Thomas* R. Grillot* oi63-4453/93/o2o22I + I2 $08.00/0 © I993 The British Society for the Study of Infection
222 Letters to the Editor
R e f e r e n c e s
I. Sugar AM. Overview: cryptococcosis in the patient with AIDS. Mycopathologia I99I ;
I I 4 : I53-I57.
2. Grant SM, Clissod SP. Fluconazole : a review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in superficial systemic mycoses. Drugs ~99o; 39:
877-916.
3. Denning DW, Tucker RM, Hostetler JS, Stratpreet G, Stevens DA. Oral Itraconazole therapy of cryptococcal meningitis and cryptococcosis in patients with AID S. In: Vanden Bossche H, Ed. Mycoses in AIDS patients. New York, NY: Plenum Press, I99o: 305-324.
4- Viviani MA, Tortorano AM, Giani PC et al. Itraconazole for cryptococcal infection in the
acquired immunodeficiency syndrome. Ann Intern Med I987; xo6: I66.
5. De Gans J, Eeftink Schattenkerk JKM, Van Ketel RJ. Itraconazole as maintenance treatment for cryptococcal meningitis in the acquired immune deficiency syndrome. Br MedJ I988; z96: 339.
C l e n c h e d fist a c t i n o m y c o s i s i n a p e n i c i l l i n - a l l e r g i c f e m a l e
Accepted for publication 24 April I992
Sir,
Clenched fist actinomycosis is rare c o m p a r e d with other clenched fist injuries, and has hitherto been reported exclusively in males.1 T h i s infection m a y result in osteomyelitis of the h a n d bones as r e p o r t e d by B l i n k h o m et al., 2 who reviewed eight other cases in
the literature.
W e n o w report the case of a 33-year-old female fish packer, who presented with pain and a I cm diameter fluctuant abscess on the d o r s u m of the second metacarpophalangeal joint of the index finger of the right hand. She had been involved in a fight a m o n t h earlier, during which she p u n c h e d her o p p o n e n t in the teeth. T h e r e was no lymphangitis or axillary l y m p h a d e n o p a t h y , no signs or s y m p t o m s of systemic sepsis and she was able to extend the finger fully. She was allergic to penicillin and was prescribed oral erythromycin, 500 m g q.d.s, and asked to r e t u r n that afternoon for incision and drainage. She did not attend until 4 days later, w h e n the w o u n d was incised and curetted u n d e r general anaesthetic. G r a m - s t a i n s of pus f r o m the w o u n d showed n u m e r o u s pus cells and G r a m - p o s i t i v e b r a n c h i n g bacilli. A p r e s u m p t i v e diagnosis of Actinomyces spp. infection was made. T h e patient returned a m o n t h later
because of increasing pain and swelling. T h e abscess was n o w 2 cm in diameter. X - r a y and another incision and drainage showed no evidence of septic arthritis or osteomyelitis. G r a m - s t a i n s of the pus showed G r a m - p o s i t i v e b r a n c h i n g bacilli and G r a m - n e g a t i v e bacilli. Culture on blood agar and C o l o m b i a Blood Agar base with added antibiotics (Metronidazole 2"5 mg/1 and Nalidixic acid 5o mg/1) yielded a m o d e r a t e growth of Actinomyees israelii in both media. T h e C o l u m b i a Blood Agar also
yielded a m o d e r a t e g r o w t h of Bacteroides ureolyticus and Haemophilus paraphrophilus.
All isolates were susceptible to penicillin G (I I U ) , e r y t h r o m y c i n ( 5 # g ) and tetracycline ( I o #g) on disc susceptibility testing by the Stokes m e t h o d . T h e patient was given oral doxycycline 200 m g stat followed b y IOO m g daily. Local pain and swelling i m p r o v e d and the patient was discharged after 3 days. F o l l o w - u p 4 and I2 days later showed progressive diminution in the size of the lesion and a full range of m o v e m e n t s of t h e finger. T h e patient failed to attend subsequent follow-up a p p o i n t m e n t s b u t was seen I I weeks after initial presentation for an unrelated injury, w h e n her lesion was noted to have healed completely.
T h i s case underlines the value of m i c r o s c o p y of pus samples f r o m cases of h u m a n bite injuries in the p r e s u m p t i v e diagnosis of actinomycosis. N o t infrequently, as in o u r case, other m o u t h ' c o m m e n s a l s ' are encountered in actinomycotic wounds, for example, Haemophilus spp., Baeteroides spp., Actinomyces actinomycetocomitans.., etc.
