The Clinical Features and Outcomes of Patients with Cryptococcosis After Renal Transplantation

Xu Shu-Tian, Li Shi-Jun, Chen Jing-Song, Wen Ji-Qiu,, Hu Wei-Xin, Liu Zhi-Hong*

National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210016, China

Objective: To retrospectively investigate the clinical features and outcomes of patients with cryptococcosis after kidney transplantation.

Methodology: In this study, we examined a total of 6 patients, 3 male and 3 female, with cryptococcosis after renal transplantation. We analyzed their clinical manifestations, laboratory data, skin tissue pathological features, treatment and prognosis. 

Results: All patients except one originally presented with chronic glomerulonephritis, while the other presented with primary hyperoxaluria type 1. All of these patients received renal transplants for the first time. The disease occurred within a median of 6 years after transplantation.  All of the patients were HIV negative, two were HBV positive, and one had HCV co-infection. Complications included 3 patients with diabetes mellitus and 3 with hypertension. Only one patient had definite contact with bird droppings; the others were undetermined. There were headache, fever, and different degrees of consciousness central nervous system disorder in every patient: 3 had seizures, 5 were positive for signs of meningeal irritation, 2 had blurred vision, and one was hearing impaired. All patients experienced loss in body weight, low counts of CD4 + and CD8 + T lymphocytes,varying degrees of anemia, low albumin and prealbumin, renal dysfunction and raised intracranial pressure (23.5~41 cm H2O). Cerebrospinal fluid (CSF) analysis showed low glucose and high protein levels. Multiple tests were used to determine cryptococcosis infection: 5 patients were diagnosed with cryptococcosis in CSF by India ink; the presence of cryptococcosis was confirmed in 4 patients by CSF culture;cryptococcal fungemia was identified in 3 patients by blood culture; 3 patients had cutaneous disseminated cryptococcosis confirmed by skin tissue biopsy; 2 cases had yeast coinfection;and 4 patients were diagnosed with systemic disseminated cryptococcosis. According to a drug sensitivity test, fluconazole was given to 4 patients, itraconazole was given to another, and the last one was given fluconazole and then voriconazole. Finally, 3 patients survived, however maintaining hemodialysis; 3 patients died.

Conclusion: Cryptococcosis in renal allograft recipients can disseminate to the skin,leading to easy misdiagnosis. Thus, it is necessary to make appropriate tissue biopsy and special stains to establish the correct diagnosis. Early diagnosis and timely treatment is the key to improve treatment success.