A 56 year-old caucasian male was admitted due to fever of unknown origin. He had end stage renal disease due to a rapidly progressive IgA nephropathy treated with cyclophosphamide for 6 months (cumulative dose 21.6 g) plus prednisone. Was on hemodialysis since April 2005 (day - 2355). He also had a prior history of Polycythemia Vera diagnosed in 2001 (day - 3566), arterial hypertension, rickettsiosis diagnosed and treated on May 2010 (day - 441), and pulmonary tuberculosis infection, with clinical response to treatment.
Patient was submitted to deceased-donor renal transplant on 1st of September 2011 (day - 0). Induction immunosuppression was performed with basiliximab, tacrolimus, MMF, and prednisolone. Post-surgery was complicated with infected retroperitoneal hematoma (treated with meropenem and vancomycin), surgical wound infection by Pseudomonas aeruginosa (treated with ciprofloxacin plus ceftazidime), and Candida albicans oropharyngitis (resolved with fluconazole).
Allograft presented delayed graft function and later, acute vascular rejection (Banff IIA) for which ten doses of Anti-thymocyte globulin (ATG) were administered (day - 35).
Due to persistent fever and sepsis with negative blood cultures, and failure to recover renal function, patient was submitted to transplantectomy 3 months later (day - 88). Cultured fluid collected from the abdominal drain placed in the area of the removed allograft was positive for C. neoformans. Allograft histology also revealed the presence cryptococcus. Normal opening pressure was found on lumbar puncture, with negative India-ink CSF.
On day 89 patient was started on liposomal amphotericin B (1.0 mg/kg per day IV) for four weeks, with complete resolution of symptoms. He progressively recovered and was discharged under fluconazole (200 mg per day, oral).