Cryptococcosis in Pediatric Renal Transplant Recipients: Comparative Insights from Adult Cases

Abstract

Cryptococcosis, an opportunistic fungal infection predominantly caused by Cryptococcus neoformans, is the third most common invasive fungal disease in solid organ transplant recipients. While well-characterized in adult kidney transplant (KT) patients, pediatric data remain sparse. This article compares clinical presentation, immune response, renal involvement, and management strategies of cryptococcosis between adult and pediatric KT recipients. In adults, the disease typically presents as cryptococcal meningitis or pulmonary infection, often complicated by delayed diagnosis and high mortality. In contrast, children frequently exhibit non-specific respiratory symptoms or disseminated disease, reflecting immune immaturity and increased susceptibility to hematogenous spread. Key immunopathological differences include impaired Th1 type responses, macrophage dysfunction, and variable complement activity across age groups. Management involves similar antifungal regimens such as liposomal amphotericin B, flucytosine, and fluconazole, but requires weight-based dosing and careful toxicity monitoring in pediatric patients. Early diagnosis through serum cryptococcal antigen screening, appropriate adjustment of immunosuppressive therapy, and coordinated multidisciplinary care are essential. The findings underscore the need for pediatric specific research and clinical vigilance, emphasizing tailored antifungal dosing and individualized immune management to improve outcomes in this vulnerable population.

Keywords: Cryptococcus; central nervous system; chronic kidney disease; cutaneous localization; imaging; infectious disease; liver; lungs; neurological involvement; neurology; pediatry; pulmonary; transplantation.

Figure 1

Differences in symptoms and therapeutic management of Cryptococcosis in adults and children. Legend: This figure compares the pathogenesis, clinical manifestations, and treatment considerations of cryptococcosis in adult and pediatric patients. In adults, Cryptococcus often disseminates to the liver, skin, urinary tract, and bones, primarily due to CD4+ T cell depletion and macrophage dysfunction. In children, the immature immune system contributes to dissemination to the blood, skin, and central nervous system (CNS). The immune reconstitution inflammatory syndrome (IRIS) can worsen cryptococcal meningitis (CM) symptoms, increase intracranial pressure, and lead to neurological deterioration in adults, while in children it typically results in heightened inflammation and tissue damage. Therapeutic approaches are similar in both groups, including amphotericin B, flucytosine, and fluconazole. Pediatric management, however, requires careful monitoring for liver, renal, and hematologic toxicity, with particular attention to the risk of myelotoxicity. Created with BioRender.com.