Disseminated Cryptococcosis in an HIV-Negative Patient With Liver Cirrhosis and Asplenia: A Rare but Dreadful Disease.

Cryptococcosis (cryptococcal infection) is a severe life-threatening fungal infection. It is seen worldwide, specifically in immunocompromised, mainly in human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)-infected individuals. Cryptococcal infection can present with meningitis, pneumonia, peritonitis, disseminated cryptococcosis, and cryptococcal fungemia. Here, we report the case of an HIV-negative Caucasian male in his early 50s with liver cirrhosis and asplenia who presented to our hospital with bilateral foot cellulitis and pneumonia. He was eventually diagnosed with disseminated cryptococcosis. Even with appropriate treatment, he developed multiorgan failure and finally expired. The disseminated cryptococcal infection has a very high mortality rate in patients with liver cirrhosis and asplenia. Liver cirrhosis is an independent risk factor, and asplenia is a comorbid condition for cryptococcal infection in HIV-negative patients. Healthcare providers should have a high suspicion of cryptococcosis in these patients. Early testing with cryptococcal antigen assay and initiation of an appropriate antimicrobial regimen can help minimize bad outcomes.

Limited Granulomatosis With Polyangiitis Presenting as Recurrent Lung Abscess Without Pneumonia.

Granulomatosis with polyangiitis (GPA), previously called Wegener's granulomatosis, is a systemic necrotizing vasculitis affecting small and medium-sized vessels and is associated with antineutrophil cytoplasmic antibodies (ANCA). GPA is a systemic disease but can present in a limited form, where the respiratory system is the most commonly involved. Here, we report a case of a 54-year-old African American female who presented with chronic cough and got diagnosed with recurrent right-sided empyema without pneumonia. She underwent a right thoracotomy, and the biopsy showed necrotizing granulomatous inflammation with vasculitis and rare non-necrotizing granuloma, suggesting GPA. Diagnosis of GPA was confirmed by strongly positive anti-proteinase 3 ANCA antibodies. Interestingly, her GPA is a limited form, and she had an excellent recovery after initiation of immunosuppression. Early diagnosis and treatment are critical for better outcomes and survival in GPA.

Emphysematous Pyelonephritis Involving Native Kidneys and a Transplanted Kidney.

Emphysematous pyelonephritis (EPN) is an acute severe necrotizing form of UTI, with air collection in the renal parenchyma, collecting system, and surrounding tissues. Most common causative organisms are Escherichia coli and Klebsiella. Here we present a 71-year-old Caucasian male with multiple medical problems who was transferred to our ER from a long-term acute care hospital (LTACH) for hematuria, UTI, and septic shock. He is a recipient of a deceased donor renal transplant and was receiving IV amphotericin B for recent cryptococcal meningitis. CT abdomen showed bilateral EPN, including the transplanted kidney. He received aggressive fluid resuscitation, vasopressors, and IV antibiotics and got admitted to the ICU. Unfortunately, his clinical course worsened and required ventilatory support, and his family opted for comfort care because of the high mortality rate. The emphasis of this case report is to investigate immunocompromised patients presenting with UTIs for EPN.

Primary Effusion Lymphoma Presenting As Parapneumonic Pleural Effusion.

Primary effusion lymphoma (PEL) is a rare form of high-grade non-Hodgkin's lymphoma that usually occurs in patients with compromised immunity or human immunodeficiency virus (HIV) infection. PEL is a B-cell lymphoma that principally presents as effusions without a tumor mass. We present a case of a 56-year-old African-American male with a medical history of HIV admitted to the hospital with right lung lower lobe pneumonia and parapneumonic effusion. Thoracentesis and pleural fluid cytology led to the diagnosis of PEL. He received treatment with chemotherapy and antiretroviral therapy (ART). The emphasis is to investigate immunocompromised patients presenting with pleural effusion for PEL, as it is a rare ailment with a high mortality rate.

Pseudohyperkalemia in a Patient With Chronic Lymphocytic Leukemia.

Hyperkalemia is a common electrolyte disorder with potentially life-threatening consequences, including cardiac dysrhythmias. Pseudohyperkalemia must always be ruled out before implementing treatment for true hyperkalemia. Here, we present a case of a 63-year-old male with chronic lymphocytic leukemia (CLL) with a white blood cell count greater than 200 thousand/mm3 and persistently high serum potassium concentration as high as 8.4 mmol/L. A venous blood gas analysis was performed, which confirmed the patient's plasma potassium levels were within the normal range (3.7-4.4 mmol/L). In patients with CLL, due to the increased fragility of their white blood cells, mechanical stress such as centrifugation can lead to cell lysis resulting in pseudohyperkalemia. Our emphasis with clinicians is to familiarize themselves with these spurious laboratory values and prevent unnecessary invasive testing and treatment.

Acute Spontaneous Bilateral Adrenal Hemorrhage Presenting as Hyponatremia.

Bilateral adrenal hemorrhage is a very unusual cause of severe adrenal insufficiency and hyponatremia. It can result from trauma, infections, or antiphospholipid antibody syndrome and can be fatal if not diagnosed and treated early. Here, we present a 58-year-old Caucasian man with fatigue, altered sensorium, bradycardia, and hypotension. He denied any abdominal pain, recent trauma, or anti-platelet or anti-coagulation agents. His laboratory workup showed hyponatremia with low serum cortisol levels. He was further worked up and underwent computerized tomography (CT) of the abdomen, which showed bilateral adrenal hemorrhage. He was treated with intravenous (IV) steroids followed by oral hydrocortisone and fludrocortisone. His symptoms resolved, and he was safely discharged home. Asymptomatic bilateral adrenal hemorrhage is a sporadic disease, and it should be in the differential diagnosis for disproportionately sick people with other adrenal insufficiency features.

Acute pulmonary embolism due to right basilic vein thrombosis.

A 40-year-old African-American woman presented to the emergency room (ER) with right upper extremity pain for 3 hours after sleeping overnight on that side. She was diagnosed with basilic vein thrombosis; in the ER, she was tachycardic with minimal ambulation, prompting CT pulmonary angiogram, which confirmed right-sided pulmonary embolism. Bilateral upper and lower extremity venous Dopplers did not show any acute deep venous thrombosis. She received appropriate anticoagulation. Risk factors are a smoker and recently started contraceptive pills.