Disseminated Cryptococcal Disease with Diffuse Pulmonary Infiltrates in a Non-HIV Host.

Abstract

Introduction: We present a case of disseminated Cryptococcus in a non-HIV host, where the primary manifestation was pulmonary with diffuse pulmonary infiltrates. This patient was on high dose corticosteroids for autoimmune hemolytic anemia.

Case: A 79 year old Caucasian man with a history of autoimmune hemolytic anemia on 100 mg of prednisone daily, coronary artery disease s/p bypass surgery, ischemic cardiomyopathy, chronic obstructive pulmonary disease, sleep apnea, chronic kidney disease, and history of bilateral pulmonary emboli presented to Hematology/Oncology clinic with symptoms of productive cough, worsening shortness of breath, hemoptysis. Anticoagulation had been stopped due to symptoms. The patient was referred to the emergency department from clinic where a chest CT demonstrated numerous calcified lymph nodes and diffuses grand glass opacities worse on the right and new compared to imaging from 6 months prior. The patient was placed on empiric antibiotics for treatment of pneumonia after blood and sputum cultures were obtained. Initial blood cultures grew Cryptococcus neoformans in both sets. CSF obtained by Lumbar puncture was negative for Cryptococcal. Serum Cryptococcal antigen titer was 1:2560. Infectious disease was consulted and the patient was started on induction therapy with liposomal Amphotericin B, followed by Fluconazole consolidation therapy. Hematology/ Oncology reduced the patient's prednisone dose gradually but further complications attributed to corticosteroids eventually necessitated the need to transition to Rituximab therapy. Follow up imaging on return to pulmonary clinic demonstrated marked improvement in the bilateral infiltrates.

Discussion: This patient was unique in that he demonstrated disseminated Cryptococcus but lacked neurologic complications, which is often how disseminated disease is clinically suspected. Blood cultures resulted positive for Cryptococcus and appropriate antifungal therapy was initiated before other sites were affected. The patient was HIV negative and not a post-transplant patient but was on high dose chronic prednisone for his AIHA, and therefore immunosuppressed. Opportunistic and atypical infections should be considered in all immunosuppressed patients to aid in earlier diagnosis and prevention of further dissemination of disease and further complications.