HOARSENESS OF VOICE CAUSED BY FUNGUS CANNOT BE TREATED WITH VOICE REST: CRYPTOCOCCUS TRACHEITIS IN A SINGER

Abstract

SESSION TITLE: Chest Infections 1 SESSION TYPE: Med Student/Res Case Report PRESENTED ON: 10/09/2018 03:45 PM - 04:45 PM INTRODUCTION: Pulmonary involvement of Cryptococcus species ranges from asymptomatic colonization to multifocal consolidation and acute respiratory distress syndrome. Cryptococcal Tracheitis (CT) is an extremely rare presentation often seen in immunocompromised patients. We present a very rare case of CT with tracheal stenosis in a veteran who was eventually diagnosed with Common Variable Immunodeficiency (CVID). CASE PRESENTATION: A 69 year old veteran with history of bronchial asthma had progressive worsening of hoarseness of voice for the last 6 months. He saw an Ear, Nose & Throat specialist who advised him to rest his voice from singing occupation. Despite of it, hoarseness of voice continued to get worse. Then one day, he presented to ER with worsening of cough and dyspnea. He was diagnosed with bronchitis and was treated symptomatically. After few days, he started having severe inspiratory stridor. Computed Tomography of neck showed subglottic tracheal narrowing. Flexible bronchoscopy showed a circumferential friable mass-like processes causing narrowing of tracheal rings 1 to 4. Endotracheal biopsy showed, “tracheal mucosa with necrosis and variably sized yeast highlighted by GMS stain, suggestive of Cryptococcus”. He was treated with fluconazole and serial balloon dilatations. Due to CT, extensive immunodeficiency work-up was done and it showed low IgG and IgA concerning for CVID. Currently, he is getting IV Immunoglobulin monthly and fluconazole daily. His symptoms have improved significantly following antifungal treatment and dilatations. He is currently on surveillance for tracheal stenosis. DISCUSSION: CT with resultant tracheal stenosis is a very rare presentation of invasive cryptococcal disease. It is mostly seen in AIDS, transplant recipients, chronic steroid users, chronic liver disease, and sarcoidosis patients. Finding Cryptococcus Neoformans in tracheal mucosa led to search for underlying immunodeficiency in our case. Interestingly, CVID affects the humoral immunity and presents with recurrent bacterial infections. But rarely mycobacterial and fungal infections can be the presenting symptoms which was our patient’s initial presentation. CONCLUSIONS: This case teaches clinicians that worsening hoarseness of voice and inspiratory stridor should be evaluated further to rule out upper airway pathologies such as CT. Diagnosis of CT should prompt further investigations to rule out immunosuppressive conditions including CVID. Reference #1: 1. Extensive cryptococcal tracheitis mimicking lymphoma in an AIDS patient.Balkman JD1, Gilkeson RC. Reference #2: 2. Common variable immunodeficiency. Review Iglesias Alzueta J1, Matamoros Florí N. DISCLOSURES: No relevant relationships by Muhammad Habib, source=Web Response No relevant relationships by Mohammad Islam, source=Web Response No relevant relationships by Manish Patel, source=Web Response No relevant relationships by Thien Vo, source=Web Response