Successful use of isavuconazole as secondary prophylaxis of cryptococcal meningitis in a person living with HIV and AIDS: a case report

TL;DR

A person with HIV and AIDS successfully used isavuconazole to prevent recurring cryptococcal meningitis after initial treatment.

Contribution

This case report demonstrates the successful off-label use of isavuconazole for secondary prophylaxis of cryptococcal meningitis in an HIV-positive patient.

Findings

The patient showed neurological stabilization and CD4+ T-cell recovery with isavuconazole prophylaxis.

Isavuconazole was well-tolerated with no drug-related toxicity or recurrence of meningitis.

The drug's favorable pharmacokinetics and minimal drug interactions made it suitable for long-term use with ART.

Abstract

Cryptococcal meningitis (CM) is a severe opportunistic infection in people living with HIV (PLWH). We report a 54-year-old man with advanced HIV infection who presented with CM due to Cryptococcus neoformans. Induction therapy with liposomal amphotericin B (4 mg/kg/day) plus fluconazole (800 mg/day) was prolonged to 10 weeks because flucytosine was initially unavailable; intravenous flucytosine (25 mg/kg q6h) was introduced when accessible. Maintenance fluconazole (800 mg/day) was continued, and antiretroviral therapy (ART) with dolutegravir plus emtricitabine/tenofovir disoproxil was initiated after 8 weeks. One year later, despite virological suppression, he developed neurological deterioration compatible with recurrent CM in the absence of culture confirmation. He underwent re-induction with liposomal amphotericin B plus flucytosine, followed by off-label secondary prophylaxis with oral isavuconazole (200 mg/day). Over 6 months, he maintained HIV-RNA suppression, showed CD4+ T-cell recovery (from 94 to 165 cells/mm3), and experienced neurological stabilization without further CM episodes or drug-related toxicity. Isavuconazole’s pharmacokinetic profile, oral availability, and limited antiretroviral drug–drug interactions supported its use as extended secondary prophylaxis in this setting, although limited access in low- and middle-income countries remains a concern. This case highlights isavuconazole as a potential alternative prophylactic strategy when fluconazole is ineffective or not tolerated.

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