Background: Cryptococcosis is the third most common fungal infection in solid- organ transplant (SOT) recipients. Current treatment guidelines recommend 6-12 months of antifungal therapy; however, additional maintenance or suppressive therapy may be necessary in patients at high risk for relapse. Data regarding relapse after discontinuation of therapy are limited.

Methods: We evaluated all SOT patients with cryptococcosis diagnosed at our institution during 1996-2011. Enrollment required clinical or radiographic evidence of disease and one of the following: 1) positive culture of C. neoformans from any site; 2) positive histopathology; or 3) positive serum or CSF cryptococcal antigen. Data included transplant type, infection site, treatment [induction (IN), consolidation (CO), maintenance (MA)] and outcome. Relapse was defined as worsening radiographic findings, signs/symptoms of infection and a new positive culture or increasing cryptococcal antigen after documented clearance of infection.

Results: Eighty-three cases were identified. Mean age was 53.9 years; 71% were white and 61%, male. Most common allograft was kidney (55%), then liver (20%), heart (18%) and lung (10%). Meningitis (CNS) occurred in 50 (60%) and disease confined to the lung, in 24 (29%). Infection was diagnosed >1 year after transplantation for 65%, and in less than 6 months for 14%. Median length of therapy (IN + CO+ MA) was 308 days (CNS 250; pulmonary only, 312). Most common induction therapy in patients with CNS infection was a lipid amphotericin B preparation (41/50, 82%); 26 (52%) received concomitant flucytosine. Complete or partial response at 6 months was achieved in 53 (86%) of 62 patients; 21 (25%) patients died. Fifty-five patients off therapy at least 7 days were followed a median of 857 days (range, 7-5178 days). Based on our definition of relapse, no patients relapsed off therapy during the observation period.

Conclusions: Cryptococcosis after SOT at our institution was most common in renal transplant recipients. Duration of therapy was consistent with current guidelines (6-12 months) and was longer in patients with disease confined to the lung. Relapse was rare after discontinuation of therapy when it was administered for an appropriate duration.

Baddley, J.: Other, Pfizer, Consulting, Merck, Consulting, Mayne Pharma, Consulting. Pappas, P.: Grant/Research Support, Gilead, Other, Gilead, Consulting.

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