A Case Report of Concurrent Cryptococcal and Tuberculous Meningitis in an Immunosuppressed Renal Transplant Patient

Abstract

Infections after renal transplant are a common cause of morbidity and are commonly due to Cytomegalovirus (CMV), Cryptococcus, Mycobacterium tuberculosis, and Aspergillus. Concurrent infections with both cryptococcal and tuberculous aetiologies are rare within the central nervous system (CNS). We present a case of a 67-year-old male patient who presented with three weeks of headaches, confusion, unsteady gait, and seizures. He had type 2 diabetes mellitus and hypertension. He had a kidney transplant three years prior and was on three immunosuppressive agents. He was HIV-negative. He was evaluated and found to have cryptococcal meningitis and received appropriate treatment with liposomal amphotericin B, flucytosine, and serial lumbar punctures. He also had treatment for CMV viremia with valganciclovir. Three weeks later, after an initial good clinical response, he deteriorated with worsening confusion and persistent seizures. We re-evaluated him and found him to have brain imaging suggestive of tuberculosis. We started him on anti-tuberculous medication, and he improved significantly and was alert and seizure free at discharge home one month later. This case highlights that concurrent CNS infections with cryptococcus and tuberculosis do occur especially in patients who are severely immunosuppressed such as after a renal transplant. Failure to improve while on treatment for one CNS opportunistic infection should prompt one to investigate for other concurrent causes.

Cryptococcal Meningitis in an HIV-Negative Pulmonary Tuberculosis Patient: A Case Report

“…Despite its relatively low occurrence, the one-year mortality rate remains high, ranging between 20% and 30%, even with prolonged antifungal therapy [ 9 ]. While most cases involve immunocompromised individuals, some instances have been documented in otherwise immunocompetent patients [ 5 - 8 ]. Our elderly patient had no active HIV infection, diabetes mellitus, or ongoing immunosuppressive treatment but did have progressive pulmonary tuberculosis.…”

“…Cryptococcal meningitis is a fungal infection primarily impacting individuals with compromised immune systems such as those having AIDS, diabetes, taking immunosuppressants, sickle cell disease, and transplant patients [1][2][3][4][5][6][7]. Symptoms encompass conventional signs of meningeal involvement, such as headaches and neck stiffness, alongside systemic indications of widespread afflictions like pneumonia and dermatological manifestations.…”