Cryptococcal immune reconstitution syndrome during steroid withdrawal treated with hydroxychloroquine

Abstract

We present a case report of cryptococcal immune reconstitution syndrome (IRS), in a non HIV infected patient, which we treated with hydroxychloroquine with successful results. We briefly review cryptococcal IRS, possible mechanisms of action of hydroxychloroquine as an immunomodulatory agent, and its potential role in management of IRS.

Cryptococcosis

“…97 Immunomodulatory agents including those with anti–TNF-α activity have been used in cases of steroid-refractory IRIS. 65,98–101 Other strategies, including therapeutic lumbar drainage for intracranial hypertension 93,102 and, at times, surgical drainage of suppurative lymph nodes, 86,91 are important adjunctive measures that may be considered in severe disease. Continuation of ART in the setting of IRIS is generally recommended and has been performed safely.…”

Cryptococcosis

“…Corticosteroids have been shown to reduce the need for hospitalization and to improve short-term quality of life and functional status without increased risk of complications in paradoxical tuberculosis (TB)-associated IRIS [122]; the role of corticosteroids in cryptococcal IRIS, however, is not as well established and should be reserved for life-threatening cases, particularly in light of their association with increased mortality in one study [123]. Other antiinflammatory agents have been used in cryptococcal IRIS, but the number of patients treated with any of these agents is too small to draw substantive conclusions [86,124,125]. Other management strategies, including therapeutic lumbar drainage in the setting of intracranial hypertension [62,122,126] and, at times, surgical drainage of suppurative lymph nodes [116,117], are important adjunctive therapies that may be considered in severe disease.…”

Recent‐onset systemic lupus erythematosus complicated by acute respiratory failure

“…IRIS has been described in a variety of infections in patients without HIV in the setting of withdrawal of chronic immunosuppressant medications, including case reports of Cryptococcus-associated IRIS upon withdrawal of chronic corticosteroids in a patient with myasthenia gravis and tuberculosis-associated IRIS upon withdrawal of infliximab in patients with rheumatoid arthritis and Crohn's disease (11,12). Our patient had been tapered from 60 mg to 40 mg of prednisone; therefore, IRIS was considered in the differential of her respiratory symptoms.…”