Case Report
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. May 27, 2020; 12(5): 253-261
Published online May 27, 2020. doi: 10.4254/wjh.v12.i5.253
Transmission of cryptococcosis by liver transplantation: A case report and review of literature
Gustavo de Sousa Arantes Ferreira, Andre Luis Conde Watanabe, Natalia de Carvalho Trevizoli, Fernando Marcus Felippe Jorge, Carolina de Fatima Couto, Priscila Brizolla de Campos, Gabriel Oliveira Nunes Caja
Gustavo de Sousa Arantes Ferreira, Andre Luis Conde Watanabe, Natalia de Carvalho Trevizoli, Fernando Marcus Felippe Jorge, Carolina de Fatima Couto, Priscila Brizolla de Campos, Gabriel Oliveira Nunes Caja, Department of Liver Transplantation, Instituto de Cardiologia do Distrito Federal, Brasilia 70673900, Brazil
Author contributions: Trevizoli NC and Watanabe ALC designed the report; Ferreira GSA, Couto CF and Caja GON collected the patient’s clinical data; Ferreira GSA and Couto CF analyzed the data and wrote the paper; de Campos PB and Jorge FMF reviewed the paper.
Informed consent statement: Consent was obtained from the patient, and the signed Informed Consent Form was provided to the publisher.
Conflict-of-interest statement: The authors declare no conflicts of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Gustavo de Sousa Arantes Ferreira, MD, Surgeon, Teacher, Department of Liver Transplantation, Instituto de Cardiologia do Distrito Federal, Setor HFA - Hospital das Forças Armadas - Setor Sudoeste, S/Nº, Brasilia 70673900, Brazil. gustferr@ufmg.br
Received: December 18, 2019
Peer-review started: December 18, 2019
First decision: January 19, 2020
Revised: January 24, 2020
Accepted: April 18, 2020
Article in press: April 18, 2020
Published online: May 27, 2020
Processing time: 160 Days and 14.5 Hours
Abstract
BACKGROUND

Cryptococcosis is a fungal infection caused by the yeast-like encapsulated basidiomycetous fungus of the Cryptococcus neoformans (C. neoformans) species complex. These fungi are ubiquitous in soil and bird droppings, and infection by them is an important global health concern, particularly in immunosuppressed patients, such as organ transplant recipients and those infected by the human immunodeficiency virus. The fungus usually enters the body through the respiratory tract, but extremely rare cases of infection acquired by transplantation of solid organs have been reported.

CASE SUMMARY

We report a case of disseminated cryptococcosis in a liver transplant recipient, diagnosed 2 wk after the procedure. The patient initially presented with fever, hyponatremia and elevated transaminase levels, manifesting intense headache after a few days. Blood cultures were positive for C. neoformans. Liver biopsy showed numerous fungal elements surrounded by gelatinous matrix and sparse granulomatous formations. Magnetic resonance imaging of the brain showed multiple small lesions with low signal in T2, peripheric enhancement and edematous halo, diffuse through the parenchyma but more concentrated in the subcortical regions. Treatment with amphotericin B for 3 wk, followed by maintenance therapy with fluconazole, led to complete resolution of the symptoms. The recipients of both kidneys from the same donor also developed disseminated cryptococcosis, confirming the transplant as the source of infection. The organ donor lived in a rural area, surrounded by tropical rainforest, and had negative blood cultures prior to organ procurement.

CONCLUSION

This case highlights the risk of transmission of fungal diseases, specifically of C. neoformans, through liver graft during liver transplantation.

Keywords: Cryptococcosis; Liver transplantation; Cryptococcus neoformans; Case report; Immunosuppression; Fungal infection

Core tip: Transmission of cryptococcosis through a liver graft during transplantation is an exceedingly rare occurrence, with less than 10 cases reported in the literature. Many of these patients either died or were followed for only a short period of time prior to the report, so there is little information about long term follow-up of patients with this condition. We report the case of a patient who acquired disseminated cryptococcosis from a liver graft during transplantation and was successfully treated, along with the results of follow-up biopsies and imaging exams up to 3.5 years after the transplant.