From Covid to Bovid to Ovid: A Case of Disseminated Cryptococcus Neoformans
Journal of Investigative Medicine
; 71(1):235, 2023.
Article
in English
| EMBASE | ID: covidwho-2314734
ABSTRACT
Case Report Cryptococcosis is an opportunistic infection caused by the encapsulated yeast Cryptococcus, with C. neoformans and C. gattii being the most common species to cause human disease. Immunocompromised individuals are predisposed to infections with C. neoformans, which has known predilection to CNS and pulmonary lymph nodes. We present a unique case of disseminated cryptococcosis in the setting of end-stage renal disease (ESRD), cirrhosis, tumor necrosis factor inhibitor use and steroid use for COVID19. Method(s) A single-patient case report was conducted after IRB approval. Case Presentation A 55-year-old woman with uncontrolled diabetes, lupus, rheumatoid arthritis on adalimumab, hepatitis C status post boceprevir, cirrhosis, former IV drug use, and ESRD on hemodialysis via bovine arterial-venous fistula graft presented with worsening dyspnea, cough, and altered mental status. Three months prior, patient was admitted to an outside hospital for COVID19, complicated by pulmonary embolism status post anticoagulation therapy. Patient was treated with an unknown steroid regimen, which was continued by a second outside facility when symptoms failed to improve. Patient then presented to our facility 24 hours after discharge due to continued symptoms. On admission, patient was noted to have altered mentation and hypoxia with pulmonary edema on chest x-ray and was urgently hemodialyzed. Further work-up was obtained due to non-resolving symptoms, including blood and sputum cultures, cocci serology and QuantiFERON gold. CT chest revealed bilateral consolidations. Patient was started on antibiotics for presumed hospital-acquired pneumonia. During the hospital stay, preliminarily blood cultures grew yeast and patient was started on Micafungin. However, Micafungin was changed to Liposomal Amphotericin B as ovoid structures seen on gram stain could not confirm nor rule out cryptococcus. Subsequent bronchial wash and bronchoalveolar lavage cultures, as well as final blood cultures resulted Cryptococcus neoformans. Serum cryptococcus antigen returned reactive, titer 1512. Antibiotics were discontinued and Isavuconazonium was started with Liposomal Amphotericin B. Due to recurrent headaches, lumbar puncture was obtained and revealed lymphocytic pleocytosis without cryptococcal antigenicity. Patient completed 14 days of Liposomal Amphotericin B and Isavuconazole with continuation of Isavuconazole upon discharge. Conclusion(s) Disseminated cryptococcosis in non-HIV patients is rare in the modern HIV era. Clinicians should be aware and include it in their differential of any patient with multiple risk factors for opportunistic infection. In patients with cirrhosis and ESRD, treatment is limited given altered pharmacokinetics. Studies have shown improved survival with the addition of Isavuconazole in patients with disseminated cryptococcosis with CNS involvement in the setting of chronic liver disease and ESRD.
adult; anticoagulant therapy; antigenicity; blood culture; bovine; cancer patient; cancer recurrence; cancer survival; case report; central nervous system cryptococcosis; chronic liver disease; clinical article; complication; conference abstract; coronavirus disease 2019; coughing; cryptococcosis; Cryptococcus neoformans; diabetes mellitus; drug therapy; dyspnea; end stage renal disease; female; Filobasidiella; fistula; Gram staining; hemodialysis; hepatitis C; hospital acquired pneumonia; hospitalization; human; human cell; Human immunodeficiency virus; human tissue; human versus nonhuman data; hypoxia; liver cirrhosis; lung edema; lung embolism; lung lavage; lymphocyte; mental health; middle aged; nonhuman; opportunistic infection; pharmacokinetics; pleocytosis; postdural puncture headache; rheumatoid arthritis; risk factor; serology; sputum culture; survival; systemic lupus erythematosus; thinking; thorax radiography; tumor necrosis; yeast; adalimumab; amphotericin B lipid complex; antibiotic agent; antigen; boceprevir; isavuconazole; isavuconazonium; micafungin; steroid; tumor necrosis factor inhibitor
Full text:
Available
Collection:
Databases of international organizations
Database:
EMBASE
Language:
English
Journal:
Journal of Investigative Medicine
Year:
2023
Document Type:
Article
Similar
MEDLINE
...
LILACS
LIS