Corticosteroids/hydroxychloroquine/mycophenolate-mofetil

Abstract

A 46-year-old woman developed pulmonary and osseous cryptococcosis during treatment with hydroxychloroquine, methylprednisolone, mycophenolate-mofetil and prednisone for Sjogren's syndrome (SS) [routes and times to reactions onsets not stated; not all dosages stated].The woman, who did not have a history of tobacco and alcohol consumption, was diagnosed with SS (February 2015). She started receiving methylprednisolone 40mg each day, prednisone and hydroxychloroquine 200mg twice a day to suppress the excessive immune infammation. Concomitantly, she was treated with immune-globulin [immunoglobulin] to modulate the immunity. She experienced temporary relief; however, the limb numbness aggravated in March 2015. She started receiving mycophenolate mofetil 1.0 g/day along with ongoing hydroxychloroquine, prednisone and methylprednisolone, leading to alleviation of the symptoms. However, she was hospitalised with a 1-month history of aggravated limb numbness, weakness and shortness of breath on 4 November 2016. Examination showed decreased pulmonary sounds in the lower lobe of the left lung along with a few wet rales. Also, she had declined muscle strength and superfcial sensory and positional hypoaesthesia. A CT scan revealed multiple nodules in the middle lobe of the right lung and lower lobe of the left lung, which was considered to be infection. She underwent possible pathogen tests, and she tested positive for serum cryptococcal capsular polysaccharide antigen. Other tests were unremarkable. Cranial MRI showed multiple demyelinating lesions in the white matter of both the cerebral hemispheres, and CT scan showed multiple high-density lesions in the lumbar vertebrae. An MRI showed an abnormally low signal in the corresponding vertebral bodies at T1 and T2 sequences, while a PET/CT scan demonstrated multiple lesions with high 18-F-fuorodeoxyglucose uptake in the lung and vertebral bodies. The lesions were suspected to be cancer. Lung and bone tissue biopsies showed granulomatous lesions with visible Cryptosporidium and positive ink staining and negative acid-fast staining, and the findings were consistent with Cryptococcus infection. Cryptococcus neoformans were not detected in the CSF. She was diagnosed with pulmonary and osseous cryptococcosis, and hydroxychloroquine, methylprednisolone, mycophenolate-mofetil and prednisone were considered as the risk factors for Cryptococcus infection. Also, she was diagnosed to have neurologic complications related to underlying SS.Therefore, the dose of prednisone was reduced to 10 mg/day, mycophenolate-mofetil was stopped, and she was treated with fluconazole and immune-globulin. The lung lesions were observed to have reduced on a CT scan within 3 weeks. After 3 months, the lesions had disappeared. However, the SS was active. The infection had not been fully controlled; however, she was treated with a higher dose of prednisone (30 mg/day) since the day 45 after the treatment of fluconazole. Both, the infection and neurological symptoms, were controlled during the period of 1-y...