[The 480th case:membranous nephropathy combined with diabetic nephropathy, nephrotic syndrome, and recurrent fever].

A 66-year-old male presented with edema for 10 months and high fever for half a month. The patient was diagnosed with type 2 diabetes for 10 years. Renal biopsy revealed membrane nephropathy combined with diabetic nephropathy. A combination regimen with rituximab (1 g, day 1 and day 20), cyclophosphamide (100 mg/d) and prednisone (60 mg/d) was initiated. The dose of prednisone was gradually reduced to 17.5 mg/d within 1.5 months after partial remission of nephrotic syndrome. However, the patient was re-admitted due to high fever, productive cough and mild hand tremor. The lung imaging suggested the diagnosis of community-acquired pneumonia. Ertapenem (1 g/d) was empirically administrated and adjusted to moxifloxacin (0.4 g/d) plus ceftazidime (2 g, 2 times/d) for two weeks. The patient responded and temperature came back to normal. But the fever relapsed after the withdrawal of antibiotics. Mixed infections were suspected, but blood and sputum samples were negative for pathogens. Antibiotics were not effective. The patient recalled a history of pigeon exposure. Positive cryptococcus antigen in blood culture and cerebrospinal fluid unmasked the diagnosis of pulmonary cryptococcosis and cryptococcal meningitis. Fluconazole (200 mg, 2 times/d) and oral flucytosine (1 g, 3 times/d) were given and effective.