Tsuchida Hiroki, Ichikawa Daisuke, Shima Yoshinori, Yasuda Takashi, Sato Takeo, Kimura Kenjiro
Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Japan.
Nihon Jinzo Gakkai Shi. 2007;49(1):54-9.
A 76 year-old woman was admitted to our hospital because of pyrexia and fatigue. One year earlier, she was diagnosed as nephrotic syndrome(NS) caused by focal segmental glomerulosclerosis and immunosuppressive therapy was started with marked amelioration of proteinuria. Thereafter, her renal function worsened, but only supportive treatment was continued. After admission, a cerebrospinal fluid (CSF) examination revealed Cryptococcus neoformans (C. neoformans) by india ink staining and a subsequent CSF culture confirmed C. neoformans infection. Accordingly, we made the diagnosis of cryptococcal meningitis and immediately started multiple anti fungal drugs with dosage modification according to her impaired renal function. Immunosuppressive therapy for NS was temporarily terminated. The inflammatory signs and symptoms soon were markedly improved, but the anti cryptococcal antibody titer in the serum and CSF remained high. Immunosuppressive therapy was started again at a low dosage because urinary protein had increased again. One hundred and eight days from admission, she was discharged with a regimen of multiple anti fungal drugs. Proteinuria and renal insufficiency was almost stable during hospitalization. Most fungal infection develops in patients in an immunosuppressive state induced by immunosuppressive drugs, HIV infection and so on. Patients with NS are frequently in an immunosuppressive state because of urinary loss of immunoglobulins and the use of immunosuppressive drugs. Therefore, it should be remembered that patients with NS are at a high risk of suffering from fungal infection.
一名76岁女性因发热和疲劳入院。一年前，她被诊断为局灶节段性肾小球硬化引起的肾病综合征（NS），并开始接受免疫抑制治疗，蛋白尿明显改善。此后，她的肾功能恶化，但仅继续进行支持治疗。入院后，脑脊液（CSF）检查通过墨汁染色发现新型隐球菌，随后的脑脊液培养证实为新型隐球菌感染。因此，我们诊断为隐球菌性脑膜炎，并立即开始使用多种抗真菌药物，并根据她受损的肾功能调整剂量。NS的免疫抑制治疗暂时终止。炎症体征和症状很快明显改善，但血清和脑脊液中的抗隐球菌抗体滴度仍然很高。由于尿蛋白再次增加，以低剂量再次开始免疫抑制治疗。入院108天后，她带着多种抗真菌药物的治疗方案出院。住院期间蛋白尿和肾功能不全几乎稳定。大多数真菌感染发生在由免疫抑制药物、HIV感染等引起的免疫抑制状态的患者中。NS患者由于免疫球蛋白的尿丢失和免疫抑制药物的使用，经常处于免疫抑制状态。因此，应该记住，NS患者有很高的真菌感染风险。
