IN THE HEART OF IT: A RARE PRESENTATION OF DISSEMINATED CRYPTOCOCCUS

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Since the emergence of highly active antiretroviral therapy (HAART), incidence cryptococcosis has fallen. We discuss a rare presentation of disseminated cryptococcosis. CASE PRESENTATION: A previously well 31 year old woman presented with 3 weeks of nausea, vomiting & headache. She was sent to hospital when she developed dizziness & palpitations after a positive HIV test was found on an outpatient visit. Examination revealed diffuse adenopathy. Urine was positive for opiates, cannabinoids & barbiturates. Non-contrast computed tomography head revealed no acute abnormalities, but abdomen/pelvis found abdominal & retroperitoneal lymphadenopathy. On day 2, she developed diaphoresis, cold extremities with HR160bpm, BP89/53mmhg, RR44bpm, SpO289% & T100F. She was intubated & put on vasopressors. She subsequently had 3 PEA cardiac arrests with return of spontaneous circulation after several minutes. Bedside transthoracic echocardiogram (TTE) revealed a severely hypokinetic dilated right ventricle (RV) & underfilled left ventricle (LV). Bedside transesophageal echocardiogram noted hyperdynamic apex, akinetic base & echogenic material within the right pulmonary artery, concerning for a pulmonary embolism. Hemodynamic instability was refractory to thrombolytics & she was placed on veno-arterial ECMO. She was empirically given vancomycin, piperacillin-tazobactam & clindamycin/primaquine. Blood cultures were later positive for yeast, so caspofungin & fluconazole added. Follow-up TTE showed minimal improvement in RV or LV function. On day 3, after 24 hours off sedation, pupils were dilated & brainstem reflexes absent. Apnea test confirmed brain death. After expiration, HIV viral load was found to be 528,000 copies/ml (reference range: not detected), CD4 was <20 cells/mcl (490-1740cells/mcl), & Cryptococcus neoformans was isolated, with titer ≥1:2560 (normal: negative). DISCUSSION: Cryptococcosis is the most common fungal disease in HIV, but its incidence has decreased in the US. Earlier HIV diagnosis & HAART explain this. It most commonly affects the nervous system. Occasionally, blood cultures are positive indicating disseminated disease. We postulate that pulmonary vascular occlusion can occur due to disseminated cryptococcal infection. Cryptococcomas are extremely rare solid tumor-like masses which have been reported to invade the central nervous system & the skin. Our suspicion for this is high given her poor response to TPA & significant fungemia which likely led to right heart failure & cardiovascular collapse. Literature review identified one other such case. More common sequelae include meningitis or pulmonary involvement. Amphotericin B & Flucytosine represent the most potent therapy for severe disease. CONCLUSIONS: Cardiopulmonary collapse from right heart failure with disseminated cryptococcus is extremely rare. Early diagnosis & treatment of HIV remains the most important tool. REFERENCE #1: Bramantono, B., Danial, A., & Hadi, U. (2020). A case of an AIDS patient with Cryptococcus neoformans infection. The Pan African medical journal, 36, 88. https://doi.org/10.11604/pamj.2020.36.88.20406 REFERENCE #2: Gültaşli NZ, Ercan K, Orhun S, Albayrak S. MRI findings of intramedullary spinal cryptococcoma. Diagn Interv Radiol. 2007 Jun;13(2):64-7. PMID: 17562509. REFERENCE #3: Sperry BW, Howard EW, Gitterman S, Panza JA. A case of cryptogenic dyspnea: disseminated cryptococcosis. Am J Med. 2014 Aug;127(8):707-10. doi: 10.1016/j.amjmed.2014.04.007. Epub 2014 Apr 21. PMID: 24769024. DISCLOSURES: No relevant relationships by Janeen Grant-Sittol, source=Web Response No relevant relationships by Lena Makartian, source=Web Response No relevant relationships by Priya Patidar, source=Web Response No relevant relationships by Rani Sittol, source=Web Response