Effective Voriconazole in an Immunocompetent Patient With Amphotericin B Resistant Systemic Cryptococcal Granulomatosis

The diagnostic management of systemic granulomatosis is a difficult clinical exercise. The most frequent etiologies are tuberculosis and sarcoidosis. However, it is important to search as well for the other causes of granulomas, especially infections and malignancies, the prognosis of which can be poor without adequate treatment. A 67-year-old immunocompetent patient presented with granulomatous adenitis without caseous necrosis. The etiological evaluation had revealed neurological, pulmonary and lymph node systemic cryptococcosis. Conventional antifungal therapy with the triple combination Amphotericin B - Flucytosine - Fluconazole has not been effective, indicating administration of voriconazole. The evolution was rapidly favorable with apyrexia after 48 hours, disappearance of clinical symptoms, normalization of biological parameters of cerebrospinal fluid (CSF) and major improvement of radiological abnormalities. This clinical case is original by the disseminated involvement, the patient's non-immunocompromised status and the primary resistance to amphotericin B. Our findings underline the importance of carrying out an exhaustive evaluation, reflecting on cryptococcosis in any systemic granulomatosis and knowing the various therapeutic alternatives, in particular, voriconazole if primary response to amphotericin B has not been obtained.