Mycophenolate-mofetil/prednisone/tacrolimus

Author Information

An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

A 45-year-old man developed cryptococcal meningitis and COVID-19 infection during immunosuppressive therapy with prednisone, tacrolimus and mycophenolate mofetil.

The man, who had a medical history of end-stage renal disease and kidney transplant, presented with severe headaches, vomiting, neck pain and nausea for the previous week. He had been receiving prednisone, tacrolimus and mycophenolate mofetil. Investigation showed body temperature 38.1°C, neck pain and photophobia. Lumbar puncture showed an opening pressure of 45cm with CSF showing 108 WBCs with 67% neutrophils and increased protein. Based on these findings, cryptococcal meningitis was suspected.

Then, the man was treated with induction therapy with amphotericin B and flucytosine. The CSF and serum cryptococcal antigens returned positive at 1:320 and 1:2560, respectively. CSF culture grew Cryptococcus neoformans/gattii complex. Subsequently, he underwent serial lumbar punctures and completed 14 days of induction therapy. Later, he was switched to fluconazole. He acutely developed a severe leucopenia along with profuse diarrhoea. Over the following 1−2 days, he developed progressive cough and dyspnoea followed by hypotension, tachycardia, and hypoxemia. He was found to be positive for SARS-CoV-2 infection. He received an off label treatment with dexamethasone and unspecified broad spectrum antibactrials [antibiotics], and oxygen therapy. Then, he was transferred to the ICU. He was noted to have Klebsiella pneumoniae bacteremia. He developed progressive multi-organ failure and suffered a cardiac arrest. Thus, he was transitioned to comfort care. However, he died [an immediate cause of death not stated]. Further, it was confirmed that his cryptococcal meningitis and COVID-19 infection were associated with immunosuppressive therapy with prednisone, tacrolimus and mycophenolate mofetil.