Successful treatment of disseminated cryptococcosis in a liver transplant recipient with fluconazole and flucytosine, an all oral regimen.

Amphotericin B, with or without 5-flucytosine, is currently the therapy of choice for cryptococcal infections. However, amphotericin B, is nephrotoxic and requires long-term venous access for parenteral administration. The combination of fluconazole and flucytosine is synergistic in vitro against Cryptococcus. To date, however, the efficacy of fluconazole and flucytosine for cryptococcosis in liver transplant recipients has never been reported. We report a 66-year-old liver transplant recipient with disseminated invasive cryptococcus (presenting as cryptococcal subcutaneous abscess, osteomyelitis, and serum cryptococcal antigen titer of 1:32). The administration of amphotericin B for 3 weeks led to nephrotoxicity without any clinical response (persistent abscess without change in serum cryptococcal antigen titer). Fluconazole, at a dosage equivalent to 800 mg/day administered orally, and flucytosine, also given orally, led to a clinical response and a steady decline in serum cryptococcal antigen titer, which became negative at 6 weeks of therapy. The patient remains well 18 months after therapy. No adverse effects have been attributed to fluconazole or flucytosine. This combination obviates the nephrotoxicity and the need for parenteral access required for amphotericin B infusion, and it can be administered orally. The combination of fluconazole and flucytosine warrants future controlled trials for the treatment of cryptococcal infection in liver transplant recipients.