DISSEMINATED CRYPTOCOCCAL INFECTION IN AN IMMUNOCOMPETENT PATIENT

Document Type

Conference Proceeding

Publication Date

6-17-2022

Publication Title

Journal of General Internal Medicine

Abstract

CASE: Mrs R is a 49 year old female with a history of migraines who represented to medical attention with status epilepticus, a high fever to 106.7F, headaches, and encephalopathy. A month prior she presented to an outside hospital with headaches, ataxia, visual changes and confusion. An MRI brain demonstrated leptomeningeal enhancement and a CT chest demonstrated scattered pulmonary nodules that were not amenable for biopsy. She improved and left prior to lumbar puncture results. The diagnosis was a possible transient ischemic attack, discharged on acyclovir and dexamethasone. She outpatient neurology follow up for repeat imaging, but she did not attend. At our hospital, she was altered with inappropriate behavior requiring sedation and restraints. Emergent CT head and CT-angiogram were negative for stroke. She had negative urinary toxicology screen and negative alcohol level. An EEG showed moderate encephalopathy without capturing seizure activity. Patient was admitted for further workup. A repeat MRI at our facility redemonstrated scattered innumerable enhancing leptomeningeal nodules. A lumbar puncture was performed that was significant for high lymphocytes, high protein, low glucose, and an elevated ACE. Viral PCR for West Nile, HSV1 and 2, and VZV were negative. An autoimmune workup was negative for ANA, ANCA, GAD, SS-A and SS-B. She was found to have positive Cryptococcus antigen in the CSF and blood, consistent with disseminated cryptococcus. On review of the patient's social history, it was learned that she had close contacts of chickens and pigeons for the past couple of months. Patient underwent induction therapy with amphotericin/ flucytosine and was transitioned to high dose fluconazole suppression therapy for discharge. She was discharged with infectious disease follow up and pulmonology follow up for investigation of her lung nodules. IMPACT/DISCUSSION: Disseminated cryptococcus is a life-threatening disease that can cause multi-system infections. Lumbar puncture and serum antigen is warranted in patients exhibiting neurological symptoms to assess for cryptococcal meningitis. Treatment is broken down into multiple stages. First, induction therapy is initiated with amphotericin B and flucytosine for at least two weeks. Following induction, patients are maintained with consolidation therapy with high dose fluconazole for 2-3 months, followed by maintenance therapy for up to a year on lower dose fluconazole. There is concern for possible sarcoidosis, which is a known risk factor for cryptococcal meningitis. However, CSF ACE is a nonspecific measurement of neurosarcoidosis. CONCLUSION: Cryptococcal meningitis usually presents in patients with immune dysfunction, such as HIV/AIDS, autoimmune disease, malignancy, and transplanted patients on immunosuppression. We present an unusual case of disseminated cryptococcus in a patient who is immunocompetent. Consideration for cryptococcal disease should be made in patients with altered mental status and close contacts with birds.

Volume

37

Issue

Suppl 2

First Page

S445

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