PULMONARY CRYPTOCOCCOSIS IN A HIV POSITIVE INDIVIDUAL
Mosier KA, Kalsi J, and Entz A. PULMONARY CRYPTOCOCCOSIS IN A HIV POSITIVE INDIVIDUAL. J Gen Intern Med 2023; 38:S518.
J Gen Intern Med
CASE: We present the case of a 53-year-old male with a history of COPD, chronic hepatitis B, and HIV who presented for evaluation of productive cough, shortness of breath and pleuritic chest pain. Symptoms had been gradually worsening for two-weeks. He was no longer established with an Infectious Disease physician nor taking any antiretroviral medication. Initial lab work revealed a HIV viral load of 125,000 copies/ml and a CD4 count of 42 cells/μl. Further investigation revealed patchy airspace opacities in the mid-lung fields on chest x-ray, concerning for multifocal pneumonia. CT chest demonstrated ground-glass and tree-in-bud airspace opacities throughout all pulmonary lobes, with more nodular opacities seen in the left lower lobe. He was initially treated with ceftriaxone and azithromycin for community acquired pneumonia, and prednisone for coinciding COPD exacerbation. Despite 3 days of treatment, he failed to show any clinical improvement, which prompted broadening of infectious work-up. Serum cryptococcal antigen resulted positive with a titer of 1:10. Lumbar puncture was immediately performed to rule out CNS involvement, and he was started on amphotericin B while awaiting CSF cryptococcal antigen result. Within 48 hours of starting anti-fungal treatment, his shortness of breath improved drastically. Cryptococcal antigen in the CSF resulted negative, so he was deescalated to oral fluconazole. He was discharged with plan to continue fluconazole for 3 months. At follow-up appointment one month later, he continued to endorse improvement in his respiratory symptoms.
IMPACT/DISCUSSION: Pulmonary cryptococcosis is most often seen in immunocompromised patients, either as a primary infection or reactivation of a latent infection. Conditions that increase risk for pulmonary cryptococcosis include HIV infection, malignancies, chronic lung disease, and treatment with immunomodulating medications. In HIV positive patients, the presentation of pulmonary cryptococcosis is more severe, with symptoms inversely proportional to CD4 count. Most cases present with a CD4 count less than 50. Common presenting symptoms are cough, fever, dyspnea, and headache. Serum cryptococcal antigen is an excellent screening test, as it is positive in virtually all HIV patients with pulmonary cryptococcosis. This study is highly predictive of who will later develop Cryptococcal meningitis, on average detecting infection 2-3 weeks before symptoms of meningitis present. Early identification allows for treatment prior to the development of CNS manifestations, thus reducing morbidity and mortality.
CONCLUSION: Our patient highlights how pulmonary cryptococcosis presents in a patient with uncontrolled HIV. In this population, serum cryptococcal antigen is an excellent screening test as it is highly sensitive for active infection. In addition, it is predictive of patients who will later develop highly morbid cryptococcal meningitis, which allows for treatment prior to CNS involvement.