Management of Cryptococcosis in Transplant Candidates and Recipients Cryptococcosis

Cryptococcosis is the third most common invasive fungal infection in solid organ transplant (SOT) recipients, but is rare among recipients of hematopoietic stem cell transplant (HSCT). Infection often occurs a year after transplantation; however early infections are common in HSCT. Among SOT patients, donor-derived infections have been described within 3 months after transplant. The most common disease manifestations are meningitis and pneumonia. The fungi Cryptococcus neoformans and C. gattii are the main causes of cryptococcosis. Symptoms of infection are often non-specific, but meningitis should be suspected if presentation includes headache or alteration in mental status. In patients with suspected meningitis, a lumbar puncture with measurement of opening pressure is necessary. The lateral flow cryptococcal antigen assay of cerebrospinal fluid (CSF) and serum is the preferred diagnostic test, due to its rapidity, sensitivity, and cost. Current treatment guidelines recommend lipid amphotericin B in combination with flucytosine for initial treatment of meningitis, disseminated infection, or moderate to severe pulmonary infection. This is followed with oral fluconazole as “consolidation” therapy. Fluconazole alone is effective for mild to moderate pulmonary infection. For transplant patients, reduction of immunosuppression should be considered, but there is a risk of immune reconstitution syndrome.