Cryptococcus gattii infection complicated by immune reconstitution inflammatory syndrome in three apparently immunocompetent children

Background: Paediatric Cryptococcus gattii disease is rare, with only twoprevious cases recorded in the Northern Territory (NT) over the last 54 years.Immune reconstitution inflammatory syndrome (IRIS) is a recognised complicationof C. gattii infection, even in the absence of an identified immunodeficiencysyndrome; however, limited paediatric data exist. We present a series of threepaediatric patients treated for C. gattii infection in the NT during 2016/2017.

CaseDiscussions: All three cases were males aged 8–13 years at the timeof presentation. Two were Aboriginal Australians from remote NT communities,and the third was a Timorese child from a remote district in Timor‐Leste. Allcases had evidence of brain cryptococcomas, and two had associated pulmonarylesions. Each child was treated with a 6‐week induction phase of intravenousliposomal amphotericin and flucytosine and then continued on a 2‐year course oferadication oral fluconazole. Persistent high intracranial pressure (ICP)complicated each case, requiring serial lumbar punctures and, in two cases,insertion of ventriculoperitoneal shunts. All three cases were diagnosed withIRIS between 5 and 10 weeks after commencement of antifungal treatment and weremanaged with high‐dose corticosteroids, which were weaned slowly (6–20 monthspost‐commencement).

Conclusions: Paediatric C. gattii disease is rare, although threerecent cases in the NT highlight some of the challenges involved in managing theinfection, including persistent raised ICP and complications such as IRIS.There is a need for further collaborative research into paediatric C. gattiidisease.