Isolated Pulmonary Cryptococcosis in Hepatic Transplantation: Case Report and Review of the Literature

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Despite advances in the surgical and medical management of liver transplant patients, infections remain a significant cause of transplant-associated morbidity and death. Invasive fungal infections are among the leading causes of infectious complications in solid organ transplant recipients and have a comparatively much higher risk of mortality. Liver transplant recipients with invasive fungal infections have the highest mortality, a finding perhaps attributable to the acuity of their systemic illness as well as their degree of immune system compromise. Cryptococcus neoformans is the third most common fungal infection in this group.

In this article, we describe our experience with a 65-year-old patient with type 2 diabetes, ethanol abuse, and hepatitis C/cirrhosis/hepatocellular carcinoma who ultimately received orthotopic (cytomegalovirus [CMV] D+/R−) hepatic transplantation. He developed posttransplant shortness of breath, but workup of this finding was negative, and his immunosuppressive doses were slowly weaned. However, his shortness of breath continued. A computed tomography of the thorax was obtained 6 months after transplantation, and he was found to have multiple bilateral irregular opacities that were suggestive of infection. Cultures were eventually positive for C. neoformans. A CMV polymerase chain reaction also demonstrated evidence of CMV viremia at 7310 copies. Further workup was negative for central nervous system or extrapulmonary disease, and the patient was started on treatment for CMV and pulmonary cryptococcosis with good response.

In this article, we review some of the epidemiologic, diagnostic, prognostic, and management issues for cryptococcal disease in solid organ transplant recipients with a focus on hepatic transplantation. We also draw a distinction between C. neoformans and Cryptococcus gattii, a more recently characterized pathogen. Lastly, we discuss the treatment of isolated pulmonary cryptococcosis as well as central nervous system and extrapulmonary disease in this growing patient population.

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