Concurrent Disseminated Cryptococcus neoformans and Abdominal Tuberculosis in a Renal Transplant Recipient – Paradoxical Reaction or IRIS?

Abstract

A 36 year old-man diagnosed with ESRD on hemodialysis, presented with fever, moderate abdominal pain with frequent non-bloody loose stools, headache, blurring of vision and molloscum-contagiousum like skin lesions. HIV test was negative and CT brain was normal. Blood culture grew Cryptococcus neoformans with high titer antigenemia. Amphotericin B and fluconazole were started and the patient was discharged on oral fluconazole therapy. Four weeks later, he was readmitted with persistent high spikes of temperature, profuse sweating and severe frontal headache. CT brain revealed a faint hypodense lesion at right frontal lobe with ill-defined margin and lumbar puncture was deferred. Pan-sensitive mycobacterium tuberculosis was grown from stool sample. Blood cryptococcalantigenemia was reported again and he was started on a new IV amphotericin intensive cycle and high dose fluconazole. Quadruple anti-tuberculosis treatment was initiated. The patient made a full clinical recovery including total resolution of skin lesions; laboratory and radiological recovery.