Amphotericin B-resistant pulmonary cryptococcosis isolated in a patient with human immunodeficiency virus infection: case report.

Criptococosis pulmonar resistente a anfotericina B aislada en paciente con infección por virus de inmunodeficiencia humana: reporte de caso

Cryptococcosis remains one of the main opportunistic infections in immunocompromised patients diagnosed with human immunodeficiency virus (HIV) infection. One of the mainstays of its treatment is induction therapy with amphotericin B in combination with flucytosine or fluconazole. Acquired resistance of Cryptococcus neoformans to amphotericin B is considered very rare, however, its finding is of concern due to the limited therapeutic alternatives available. We present the case of a 56-year-old transsexual patient with a history of HIV infection diagnosed 13 years ago, the last two years without HAART therapy. She was admitted for chronic diarrhea of 6 months of evolution and involuntary weight loss of 8 kg in 2 months.  On admission, the patient was hemodynamically stable, with no positive findings on physical examination. Paraclinical findings without anemia or leukopenia, CD4 count 93 cells/mm3, and gastrointestinal FilmArray panel with evidence of infection by Cryptosporidium Sp, and Campylobacter Sp, so management was started with Nitaxozanide and Ampicillin sulbactam. In addition, the patient had respiratory symptoms due to non-productive cough, so a contrasted chest CT scan was performed with the finding of a nodular lesion with soft tissue density and small central cavitation of approximately 14 x 14.5 mm in the right lower pulmonary lobe. Given the radiological findings, the patient was evaluated by the thoracic surgery service who considered that the nodule in the right lower lobe would benefit from segmental pulmonary lobectomy by thoracoscopy for diagnosis. The patient was taken to the procedure and a pulmonary wedge sample was taken for microbiological studies, which confirmed the diagnosis of pulmonary cryptococcoma, documenting resistance to amphotericin B (MIC 1 µg/mL). Management was given for 14 days with liposomal amphotericin B 180 mg IV per day, Fluconazole 400 mg IV every 12 hours and Flucytosine 1500 mg IV every 6 hours. After 12 days of induction therapy, patient with resolution of respiratory symptoms and imaging control with resolution of the initial lesion. The patient was discharged with consolidation therapy with fluconazole 1200 mg daily for at least 8 weeks. From this case, we conclude that it is extremely important to take fungigram in the diagnostic evaluation of cases of cryptococcosis, in order to guide antifungal therapy, detect antifungal resistance in a timely manner and avoid a possible subsequent therapeutic failure.