A CRYPTIC COUGH: A RARE CASE OF CRYPTOCOCCAL PNEUMONIA

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cryptococcal pneumonia is an opportunistic fungal infection caused by Cryptococcus neoformans. Many cases initially present in the lungs of those suffering from HIV/AIDS, diabetes, or on chronic immunosuppressants1. We present a case of a 28-year-old woman with no prior medical history who develops a severe case of cryptococcal pneumonia with factors of exposure or risk. CASE PRESENTATION: 28-year-old female with no prior medical history presents in the setting of a productive cough with yellow-brown sputum for 2 weeks that increased with frequency and severity. The patient presented to the emergency department and an initial computed tomography (CT) angiogram of the chest was performed that revealed a significant left lower lobe pneumonia, leading to her admission (Figure 1). The patient was initially started on levofloxacin and linezolid;however, MRSA, blood and sputum cultures, viral panel, HIV, and Covid-19 tests were all negative. A bronchoalveolar lavage was performed which also had negative cultures and cytology. The patient began to develop fevers, and a cryptococcal antigen was tested that was positive. The patient was started on fluconazole IV, and underwent a successful left video-assisted thoracoscopic surgery (VATS) with lower lobe resection, with the pathology revealing non-necrotizing and focal necrotizing granulomas. A GMS stain revealed numerous yeast forms with narrow based budding, morphologically consistent with Cryptococcus neoformans. The patient had a lumbar puncture that was negative for Cryptococcal antigen, and patient was discharged on oral fluconazole. The fungal culture from the BAL was eventually positive for C. neoformans, 2 weeks later. DISCUSSION: Cryptococcal pneumonia of this magnitude is incredibly rare in an immunocompetent patient, especially someone as young as this patient. The patient did not have any exposure nor risk factors, yet required a VATS procedure to confirm the infection. It would be expected with a cryptococcal pneumonia this severe would produce a more systemic response;however, multiple blood cultures and lumbar punctures were negative for any dissemination. The etiology in this case is still unknown, albeit a significant amount of the population has been exposed to Cryptococcus at some point as a child, especially those living in urban areas2. Our patient was fortunate and has responded quite well to fluconazole therapy, and continues to follow up outpatient without complications. CONCLUSIONS: Cryptococcal pneumonia caused by Cryptococcus neoformans is an opportunistic fungal infection, but has the ability to cause severe illness in those immunocompetent. Blood cryptococcal antigen, lumbar puncture, and at times surgical pathology may be required for those with severe illness, and early antifungal therapy may hasten recovery. REFERENCE #1: Perfect JR, Dismukes WE, Dromer F, et al. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america. Clin Infect Dis. 2010;50(3):291-322. doi:10.1086/649858 REFERENCE #2: Goldman DL, Khine H, Abadi J, et al. Serologic evidence for Cryptococcus neoformans infection in early childhood. Pediatrics. 2001;107(5):E66. doi:10.1542/peds.107.5.e66 DISCLOSURES: No relevant relationships by Wahaaj Khan, source=Web Response No relevant relationships by Joseph Kim, source=Web Response No relevant relationships by Christian von Gizycki, source=Web Response No relevant relationships by Momina Zaman, source=Web Response