A CASE OF CRYPTOCOCCAL LAURENTII PNEUMONIA IN A PATIENT REQUIRING FREQUENT STEROID TAPERS

Abstract

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cryptococcal laurentii as a primary pathogen in infection is rare. The understanding of this non-neoformans species remains unclear as a rare virulent factor with high associated mortality or incidental finding in an at-risk immunocompromised populations. Here we present the case of a patient with chronic severe respiratory disease with acute pneumonia symptoms, found to have Cryptococcus laurentii pneumonia. CASE PRESENTATION: A 49-year-old woman with a 24 pack-year smoking history, COPD and uncontrolled severe persistent asthma, frequent hospitalizations for respiratory failure presented with acute dyspnea, wheezing and productive cough. She has previously responded to steroids, with several long tapers over the past year. A CT was performed revealing scattered ground-glass opacities, tree in bud pattern, hilar and mediastinal adenopathy, mucus plugging, and airway thickening. Initial labs were remarkable only for peripheral eosinophilia, a count of 640, with serum quantitative IgE of 33. Aspergillus testing, viral panel, COVID, and MRSA PCR were negative. Serum Quantiferon and autoimmune antibody panel were negative. The patient was started on broad-spectrum antibiotics but failed to improve. Bronchoscopy with BAL was performed, cytology showed growth of Cryptococcus Laurentii. Other respiratory samples were negative. The patient was started on a fluconazole regimen, with improvement in respiratory symptoms. DISCUSSION: Cryptococcal infection can be difficult to diagnose. Imaging and symptom presentation can be nonspecific. The most frequent symptoms are dyspnea, cough, and fever. Imaging findings can include pulmonary nodules, consolidations, nodular interstitial pattern, reticular interstitial pattern, ground glass opacities and pleural effusions. Severity can range from asymptomatic nodules to life-threatening illness. (3) There have been limited case reports of these species causing infection and pre-existing lung disease is a risk factor for pulmonary cryptococcal infection. There is a high associated risk of mortality (25-35%) (1). Due to an elevated risk of disseminated infection, diagnostic evaluation and workup should be broad and thorough. Standard cryptococcal antigen testing has worse sensitivity for non-neoformans species (3). The most appropriate treatment regimen remains contested as there has been poor correlation between in vitro antifungal susceptibility and treatment outcomes in patients (2). CONCLUSIONS: Cryptococcus laurentii remains a rare cause of infection. The symptoms may be non-specific; a high degree of suspicion is required for diagnosis. A better understanding of epidemiology and pathogenesis is crucial for improved recognition and treatment. REFERENCE #1: Shankar E. Pneumonia and pleural effusion due to Cryptococcus laurentii in a clinically proven case of AIDS. Canadian Respiratory Journal, 2006 Jul-Aug, 275-278. REFERENCE #2: Kabi S. Cryptococcus Laurentii: an unusual cause for atypical pneumonia in hematological malignancy. Journal of Mahatma Gandhi institute of medical sciences 25 (1): 45 REFERENCE #3: Smith N. Perspectives on non neoformans cryptococcal opportunistic infections. Journal of community hospital internal medicine perspectives. Oct 2017. 214-217 DISCLOSURES: No relevant relationships by Timothy Carroll, source=Web Response No relevant relationships by Suhayb Ranjha, source=Web Response