Sequelae of Cryptococcal-Immune Reconstitution Inflammatory Syndrome in a Kidney Transplant Recipient: A Case Report

RATIONALE: Cryptococcal-immune reconstitution inflammatory syndrome (C-IRIS) is a rare but recognized clinical entity in solid organ transplant recipients, though its clinical course and sequelae remain largely poorly described. PRESENTING CONCERNS OF THE PATIENT: We present the case of a kidney transplant recipient who presented with headache and fever. A cerebrospinal fluid analysis was performed and found to be compatible with cryptococcal meningitis. After down titration of immunosuppression and antifungal initiation, the patient initially improved. Weeks later, they experienced a sudden deterioration in mental status, prompting admission to the intensive care unit (ICU). DIAGNOSIS: This deterioration was attributed to C-IRIS, which developed following rapid de-escalation of immunosuppression in response to the diagnosis of cryptococcal meningitis. INTERVENTIONS: The initial episode of C-IRIS responded well to high-dose steroids; however, maintenance immunosuppression was not increased. OUTCOMES: Within 2 months, the patient presented again to the hospital with a pulmonary infiltrate and multifocal ischemic strokes. NOVEL FINDINGS: We argue this to be a case of relapsing multisystem C-IRIS, thus expanding the known spectrum of manifestations of C-IRIS in renal transplant recipients. We propose that following the diagnosis of C-IRIS, maintenance immunosuppression be escalated to avoid the risk of relapse and inflammatory-mediated organ dysfunction.