Successful Treatment of Cryptococcal Meningitis and Cryptococcoma with Isavuconazole in a Patient Living with HIV

Abstract

We describe the successful use of isavuconazole for treatment of an HIV-positive patient with cryptococcal meningitis following induction therapy with liposomal amphotericin B and flucytosine. Because the Cryptococcus neoformans isolate from cerebrospinal fluid had a borderline minimum inhibitory concentration of 8 mg/L, initial consolidation therapy was given with a daily dose of fluconazole 1200 mg based on area under the curve to minimum inhibitory concentration modelling data. Toxicity, and the radiological emergence of a cryptococcoma in the setting of immune reconstitution inflammatory syndrome, prompted a therapeutic switch to isavuconazole. Subsequent imaging after 19 weeks of isavuconazole shows a significant reduction in cryptococcoma size from 11 mm to complete resolution. The patient remains well after 210 days of therapy with a view to completion of treatment after 1 year.

Keywords: AUC:MIC ratio; HIV; IRIS; cryptococcal meningitis; fluconazole resistance; isavuconazole.

Figure 1

Timeline of patient progression.

Figure 2

MRI FLAIR changes over time. Image I on admission shows no masses, Image II shows 11 mm enhancing masse in right corpus callosum and left frontal meningioma, Image III shows improvement in the right corpus callosum mass to 4 mm, Image IV shows complete resolution of the mass.