AN UNUSUAL CASE OF DISSEMINATED CRYPTOCOCCOSIS

Abstract

SESSION TITLE: Chest Infections 3 SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/08/2018 11:00 AM - 12:00 PM INTRODUCTION: Cryptococcus neoformans is frequently present as an opportunistic pathogen mainly affecting immunocompromised populations.Disseminated infection in immunocompetent population is rare.We describe one such unique case in a young male,whose sole risk factor turned out to be where he lived. CASE PRESENTATION: 23 year old male,non-smoker, was referred to thoracic surgery clinic from an urgent care center for abnormal CT chest. He initially presented to the urgent care center with intermittent chest pain for 2 weeks. Chest x-ray there showed left lower lobe infiltrates and he was treated with oral antibiotics.On persistence of symptoms,he had a CT chest which showed bilateral lower lobe consolidations,hilar and mediastinal lymphadenopathy. He attested to low grade fevers but denied other complaints. Due to concern for possible malignancy he underwent a PET CT,which showed the lower lobe masses to be have FDG uptake of SUV 3.3.It also revealed an expansile bone lesion in the mandible with similar FDG uptake.He then underwent a wedge biopsy of his left lower lobe lesion. Histopathological examination of the specimen revealed organizing pneumonia with fungal organisms consistent with crytococcus neoformans. Cultures were negative.On detailed interview,it was found he lived near a train station which has been a nesting place for pigeons and other birds. Complete work up for risk factors including HIV infection was negative.Patient was started on itraconazole with good clinical and radiological improvement. His 3 month follow up CT shows complete resolution of all the lung and bone lesions. DISCUSSION: Cryptococcus neoformans is ubiquitous encapsulated yeast and is generally considered as an opportunistic pathogen. The lungs are predominantly the primary locus of infection, with extra-pulmonary dissemination through hematogenous route affecting the meninges and, less commonly, the skin, bones, prostate, and other organs. Lung involvement typically consists of granulomatous reactions, and infiltrates. Most cutaneous infection occurs as a sign of disseminated Cryptococcal infection, which can be seen in 10–15% of the cases. Diagnosis is based on cultural examination of blood, cerebrospinal fluid, direct microscopic observation of the pathogen and PAS stain positivity on histochemical analysis. Our patient was negative for repeated cultures, which might indicate the insensitivity of culture at the early stage of infection. Treatment usually involves azoles and in severe cases amphotericin and surgical debridement of the lesions. CONCLUSIONS: Though historically viewed as an opportunistic pathogen, fungal diseases are rapidly increasing in incidence, in its presentation in immunocompetent patients. Our case is unique as < 10 cases has been reported in literature,of disseminated crytococcal infection in an immunocompetent adult, that did not involve the nervous system. Reference #1: 1. Ruan Q, Zhu Y, Chen S, Zhu L, Zhang S, Zhang W. Disseminated cryptococcosis with recurrent multiple abscesses in an immunocompetent patient: a case report and literature review. BMC Infectious Diseases. 2017;17:369. https://doi.org/10.1186/s12879-017-2459-9. Reference #2: S. Suchitha, C. S. Sheeladevi, R. Sunila, and G. V. Manjunath, “Disseminated Cryptococcosis in an Immunocompetent Patient: A Case Report,” Case Reports in Pathology, vol. 2012, Article ID 652351, 3 pages, 2012. https://doi.org/10.1155/2012/652351 DISCLOSURES: No relevant relationships by Anna Abbasi, source=Web Response No relevant relationships by Michael Bergman, source=Admin input No relevant relationships by Prarthna Chandar, source=Web Response No relevant relationships by Kabu Chawla, source=Admin input No relevant relationships by Sakthidev Kulandaisamy, source=Web Response No relevant relationships by William Pascal, source=Web Response No relevant relationships by Arjun Saradna, source=Web Response No relevant relationships by Shyam Shankar, source=Web Response