Fluconazole

Abstract

Lack of efficacy: case reportA 51-year-old woman experienced lack of efficacy during treatment with fluconazole for cryptococcal infection. The woman was brought to a hospital in South Africa with multiple complaints on 28 January 2021. She tested positive for COVID-19. She was found to have an active lesion of oropharyngeal candidiasis and was chronically ill-looking and dehydrated. Anamnesis revealed that she had been treated with unspecified antiretroviral therapy (ART) since 2014 after the diagnosis of HIV, and she was compliant with the ART until the COVID-19 lockdown in March 2020. She avoided visits to the health centre (because of the fear of COVID-19) and defaulted on the ART since April 2020. Following examination, she was diagnosed with COVID-19 pneumonia and HIV with defaulted ART. She was rehydrated with sodium chloride [normal saline], and she started receiving offlabel treatment with dexamethasone 6mg and a stat dose of ceftriaxone 1mg for COVID-19 pneumonia. Also, she was treated with unspecified low-molecular-weight heparins [low molecular weight heparin] and nystatin. Then, she was moved to the COVID-19 ward. Oxygen saturation improved on a face mask with oxygen. On the following day, she still tested positive for COVID-19 in addition to Treponema pallidum antibody. ART (unspecified) was re-initiated, and she started receiving unspecified tuberculosis prevention therapy (TPT) with cotrimoxazole prophylaxis. She exhibited clinical improvement initially; however, she developed confusion after 1 week. On 9 February 2021, serum cryptococcal antigen test was positive, while the tests for meningitis were unremarkable. She started receiving fluconazole protocol [route and dosage not stated] for the cryptococcal infection; however, she continued to deteriorate (lack of efficacy). In the following week, she tested positive for GeneXpert mycobacterium tuberculosis/ rifampicin sensitivity. TPT was therefore discontinued, and unspecified anti-TB treatment was started. Subsequently, the clinical diagnosis was amended to COVID-19 pneumonia, HIV and TB immune reconstruction inflammatory syndrome. She continued to test positive for COVID-19 on day 15, day 23 and day 32 after the first positive test, and she continuously deteriorated despite receiving optimum treatment. She died on 3 March 2021 [cause of death not stated].