Frequent premature ventricular contractions induced by fluconazole: A case report

Introduction

Fluconazole is commonly used to treat and prevent fungal infections caused by Candida and Cryptococcus species. Although there have been reports of fatal arrhythmias induced by fluconazole, such as torsades de pointes, there have been minimal reports of mild, non-fatal arrhythmias associated with it, which may have been overlooked in clinical practice. We encountered a case of frequent premature ventricular contractions induced by fluconazole during the treatment of HIV-related pulmonary cryptococcosis. Herein, we report a case of frequent premature ventricular contractions (PVCs) induced by fluconazole, along with a literature review.

Case presentation

A 47-year-old man diagnosed with human immunodeficiency virus-related pulmonary cryptococcosis experienced an irregular heartbeat during antifungal therapy with fluconazole at 400 mg once daily. A 12-lead electrocardiogram was conducted, which displayed frequent unifocal PVCs originating in the right ventricular outflow tract without QT prolongation. After reducing the dose of fluconazole to 200 mg once daily, the patient's symptoms slightly improved, and PVC frequency decreased on a 12-lead ECG; however, PVCs did not disappear. After discontinuing fluconazole, the symptoms improved, and a follow-up 12-lead electrocardiogram showed no PVCs.

Conclusions

We encountered the case of frequent PVCs induced by fluconazole during the treatment of human immunodeficiency virus-related pulmonary cryptococcosis. Furthermore, it was suggested that the PVC frequency was dose-dependent for fluconazole. Careful follow-up for new-onset arrhythmias and ECG evaluations are essential before and after fluconazole administration.

Cerebral Cryptococcomas: A Systematic Scoping Review of Available Evidence to Facilitate Diagnosis and Treatment

Background: Recommendations for managing patients with cerebral cryptococcomas are scarce across multiple clinical guidelines. Due to the deficiency of high-quality data coupled with an increasing number of at-risk patients, the purpose of this review is to describe the demographic characteristics, causative pathogen, intracranial imaging, surgical and/or pharmacological interventions, as well as outcomes of patients with cerebral cryptococcomas to improve recognition and management. Methods: We conducted a scoping review in accordance with the PRISMA guidelines using PubMed and Web of Science. Reports were included if the following details were presented: (1) site of infection; (2) treatment details which at least include the specific antifungal therapy administered, if applicable; and (3) patient outcome. Results: A total of 40 records representing 47 individual patients were included, of which the median age was 48.5 years, 75% were male, and 60% reported a significant past medical, surgical, or social history. C. neoformans was isolated more often than C. gattii (74% vs. 26%, respectively). Patients most often presented with headache, altered mental status and/or confusion, and vomiting occurring over a median of 30 days; though few were noted to have significant findings on physical examination. More than 50% of patients had a single cerebral cryptococcoma lesion, whereas perilesional edema was present in 73% of cases. Surgical intervention occurred in 49% of patients. An amphotericin B-based formulation was administered as “induction” therapy to 91% of patients, but combined with flucytosine or fluconazole in only 58%, for an overall median of 42 days. Fifty two percent of patients received “maintenance” therapy for a median of 126 days, in which fluconazole was most often used. Corticosteroids were administered to approximately 30% of patients for a median of 31.5 days. Overall, mortality was 34%. Conclusion: Based on our findings, management should include antifungal therapy for a minimum of 6 months with considerations for concomitant corticosteroids in the setting of perilesional edema, as well as surgical intervention. Emphasis should be placed on providing well-documented treatment details in future case reports and series to allow for the development of more concise evidence-based recommendations.

Cerebellar Cryptococcoma in an Immunocompetent Adult: A Rare Occurrence Report of a Case and Review of Literature

This study reports a rare case of cryptococcoma of the brain and review the related literature. An intracranial lesion, in a healthy, middle-aged adult who underwent surgery with a preoperative diagnosis of neoplastic/metastatic lesion, which turned out to be cryptococcoma, is being reported. Histopathological examination revealed that this immunocompetent patient had cryptococcoma of the cerebellum. He responded to antifungal chemotherapy (amphotericin B initially for 2 weeks and later oral fluconazole for 10 weeks) very well. Occurrence of cryptococcomas in immunocompetent patients is rare and responds to antifungal chemotherapy very well. Only six cases (including this) have been reported in literature till now.

The combination of tamoxifen with amphotericin B, but not with fluconazole, has synergistic activity against the majority of clinical isolates of Cryptococcus neoformans

BACKGROUND

Cryptococcal meningitis has fatality rates of 40%-70%, resulting in 200 000 deaths each year. The best outcomes are achieved with amphotericin combined with flucytosine but flucytosine is expensive and unavailable where most disease occurs. More effective and affordable treatments are needed. Tamoxifen, a selective oestrogen receptor modulator frequently indicated for breast cancer, has been found to have synergistic activity against the Cryptococcus neoformans type strain when combined with amphotericin or fluconazole. It is cheap, off-licence, widely available and well-tolerated, and thus a pragmatic potential treatment for cryptococcal disease.

OBJECTIVES

We wanted to determine the susceptibility of clinical isolates of C. neoformans to tamoxifen alone and in combination with other antifungals, to determine whether there is sufficient evidence of activity to justify a clinical trial.

METHODS

We used the CLSI broth microdilution protocol to test the susceptibility of 30 randomly selected clinical isolates of C. neoformans to tamoxifen, in dual combination with amphotericin, fluconazole or flucytosine, and in triple combination with amphotericin and fluconazole. Evidence of drug interactions was assessed using the fractional inhibitory concentration index.

RESULTS

The MIC50 and MIC90 of tamoxifen were 4 and 16 mg/L, respectively. The combination of tamoxifen and amphotericin suggested a synergistic interaction in 20 of 30 (67%) isolates. There was no interaction between tamoxifen and either fluconazole or flucytosine. Synergy was maintained in 3-Dimensional chequerboard testing. There was no evidence of antagonism.

CONCLUSIONS

Tamoxifen may be a useful addition to treatment with amphotericin and fluconazole for cryptococcal meningitis; a trial is justified.

A randomized open label trial of tamoxifen combined with amphotericin B and fluconazole for cryptococcal meningitis

Background: Cryptococcal meningitis is a leading cause of death in HIV-infected patients. International treatment guidelines recommend induction therapy with amphotericin B and flucytosine. This antifungal combination is most effective, but unfortunately flucytosine is expensive and unavailable where the burden of disease is greatest. Where unavailable, guidelines recommend treatment with amphotericin and fluconazole, but this is less effective, with mortality rates of 40-50%. Faster rates of clearance of yeast from cerebrospinal fluid (CSF) are associated with better outcomes - improving the potency of antifungal therapy is likely to be an effective strategy to improve survival. Tamoxifen, a selective estrogen receptor modulator used to treat breast cancer, has anti-cryptococcal activity, appearing synergistic when combined in vitro with amphotericin, and fungicidal when combined with fluconazole. It is concentrated in the brain and macrophages, off-patent, cheap and widely available. We designed a randomized trial to deliver initial efficacy and safety data for tamoxifen combined with amphotericin and fluconazole. Method: A phase II, open-label, randomized (1:1) controlled trial of tamoxifen (300mg/day) combined with amphotericin (1mg/kg/day) and fluconazole (800mg/day) for the first 2 weeks therapy for HIV infected or uninfected adults with cryptococcal meningitis. The study recruits at Cho Ray Hospital and the Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam. The primary end point is Early Fungicidal Activity (EFA-the rate of yeast clearance from CSF), over the first two weeks of treatment. 50 patients will be recruited providing ≈80% and 90% power to detect a difference in the EFA of -0.11 or -0.13 log10CFU/ml/day, respectively. Discussion: The results of the study will inform the decision to proceed to a larger trial powered to mortality. The size of effect detectable has previously been associated with reduced mortality from this devastating disease. Particular side effects of interest include QT prolongation. Trial registration: Clinicaltrials.gov NCT03112031 (11/04/2017).

Intracranial Cryptococcoma-Clinicopathologic Correlation and Surgical Outcome: A Single-Institution Experience

OBJECTIVE

To describe clinical characteristics of patients with intracranial cryptococcoma, clinicopathologic findings, and outcomes after surgery.

MATERIALS AND METHODS

Clinical data were collected from hospital case records, and pathologic confirmation was done by a neuropathologist. Clinical details, imaging features, and treatment modalities were evaluated and correlated with outcomes based on regular follow-up.

RESULTS

This case series included 5 cases of histology- and culture-proven intracranial cryptococcoma. Three patients (60%) were aged between the 3rd and 5th decades. Three cases were supratentorial in location, and 2 were in the posterior fossa. One patient presented with seizures. Three patients (60%) presented with fever. Three patients (60%) had papilledema, and 4 (80%) had signs of meningeal irritation. Four patients (80%) were immunocompetent. Only 1 patient was immunocompromised. All lesions were peripherally enhancing on computed tomography. Four of 5 patients underwent surgical decompression without any residue. Only 1 patient underwent stereotactic biopsy. All patients received antifungal therapy. One patient who was immunocompromised developed multiorgan failure and died after 2 months after surgery (20%). Of 5 cases, 4 (80%) had a good outcome with a mean follow-up of 5 years.

CONCLUSIONS

Cryptococcus gattii is a rarer species implicated in intracranial cryptococcoma that is seen along with the more common Cryptococcus neoformans. Early diagnosis and surgical decompression followed by intravenous amphotericin B therapy for at least 6 weeks and concomitant therapy with fluconazole for prolonged periods may reduce morbidity and mortality.

Drug-induced acute myocardial infarction: identifying 'prime suspects' from electronic healthcare records-based surveillance system

BACKGROUND

Drug-related adverse events remain an important cause of morbidity and mortality and impose huge burden on healthcare costs. Routinely collected electronic healthcare data give a good snapshot of how drugs are being used in 'real-world' settings.

OBJECTIVE

To describe a strategy that identifies potentially drug-induced acute myocardial infarction (AMI) from a large international healthcare data network.

METHODS

Post-marketing safety surveillance was conducted in seven population-based healthcare databases in three countries (Denmark, Italy, and the Netherlands) using anonymised demographic, clinical, and prescription/dispensing data representing 21,171,291 individuals with 154,474,063 person-years of follow-up in the period 1996-2010. Primary care physicians' medical records and administrative claims containing reimbursements for filled prescriptions, laboratory tests, and hospitalisations were evaluated using a three-tier triage system of detection, filtering, and substantiation that generated a list of drugs potentially associated with AMI. Outcome of interest was statistically significant increased risk of AMI during drug exposure that has not been previously described in current literature and is biologically plausible.

RESULTS

Overall, 163 drugs were identified to be associated with increased risk of AMI during preliminary screening. Of these, 124 drugs were eliminated after adjustment for possible bias and confounding. With subsequent application of criteria for novelty and biological plausibility, association with AMI remained for nine drugs ('prime suspects'): azithromycin; erythromycin; roxithromycin; metoclopramide; cisapride; domperidone; betamethasone; fluconazole; and megestrol acetate.

LIMITATIONS

Although global health status, co-morbidities, and time-invariant factors were adjusted for, residual confounding cannot be ruled out.

CONCLUSION

A strategy to identify potentially drug-induced AMI from electronic healthcare data has been proposed that takes into account not only statistical association, but also public health relevance, novelty, and biological plausibility. Although this strategy needs to be further evaluated using other healthcare data sources, the list of 'prime suspects' makes a good starting point for further clinical, laboratory, and epidemiologic investigation.

Coccidioidal meningitis: clinical presentation and management in the fluconazole era

Despite the advent of new antifungal agents, coccidioidal meningitis (CM) remains a difficult-to-treat condition with significant morbidity and mortality. In this study we directly compare the clinical presentation and management of patients with Coccidioides immitis meningitis in the azole era (after 1980) to that of a cohort of patients from the pre-azole era. We reviewed 30 CM cases seen at 3 Los Angeles hospitals between the years 1993 to 2008 ("2008 cohort") and compared them to 31 patients ("1980 cohort") described by Bouza et al in a previous study. The demographics and clinical presentation of patients in the 2008 cohort were similar to those of the 1980 cohort except for a higher incidence of Hispanic patients (2008: 53% vs. 1980: 6%) and a greater percentage of patients with underlying, predisposing clinical conditions (2008: 66% vs. 1980: 32%). Ten patients in the 2008 cohort had human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), a condition not reported in the earlier study. Laboratory findings were similar between the 2 groups except for a lower incidence of peripheral leukocytosis and eosinophilia in the 2008 group.There were marked differences in drug treatment between the 2 eras. In the 2008 cohort, 29 patients received fluconazole therapy: 13 were treated with fluconazole monotherapy, and 16 received a combination of fluconazole and intravenous amphotericin B. Although almost all patients (29/31) in the 1980 cohort received intrathecal amphotericin B, only 3 patients in the 2008 study received amphotericin B via this route. With respect to complications of CM, a similar percentage of patients in each cohort developed complications such as stroke and hydrocephalus. The 2008 cohort (40%) had similar mortality compared to patients in the 1980 study (39%); survivors in both groups experienced significant impairment of activities of daily living. Although recommended as first-line therapy for CM, azole-based therapies are not curative and do not necessarily prevent complications associated with the disease.CM remains a serious illness with a high rate of morbidity and mortality. Immunocompromised individuals, especially those with HIV/AIDS, are at special risk for CM and represent a greater share of the overall population with this condition. Despite the clear advantages of azole treatment in CM, new therapeutic approaches are needed to provide definitive cure and to reduce the need for long-term suppressive therapy.

Central nervous system cryptococcoma in immunocompetent patients: a short review illustrated by a new case

OBJECTIVE

Cryptococcal infection in CNS is frequently seen in HIV patients and those with other immunosuppressed conditions. However, cryptococcal granuloma in CNS in immunocompetent patient is rare. We present one new case of cryptococcoma and review literature to illustrate diagnosis and treatment of these lesions.

METHODS

We conducted literature search in Pubmed search engine of the National Center for Biotechnology Information.

RESULTS

Seventeen cases of CNS cryptoccoma in immunocompetent patients, including ours, have been reported to date. Of them, two patients had lesions inside spinal cord, and C. neoformans var. gattii was identified in three cases. All patients were symptomatic with normal immunocompetency although two patients had type 2 diabetes mellitus and one had torsades de pointes. Eight patients received surgical treatment and all were given antifungal agents except one suspected of teniasis.

CONCLUSIONS

With literature reports and our experiences, we suggest that ring shaped enhancement of mass lesion with or without cystic changes in MR scan may indicate cryptococcoma, but definitive diagnosis relies on pathology study of lesion specimen. Open surgery and anti-fungal therapy should be scheduled, and outcome of cryptococcoma is largely determined by its locations.