22 Sep 2021

12/7/20: Disseminated Cryptococcosis with cutaneous disease and meningitis

PGY3 Nora Bedrossian presented a case of a 56 year old female with history of ESRD 2/2 HTN s/p DDRT in 8/29/17 who presents with skin lesions on her thigh, shoulder, face and neck that have been worsening over the past month.  1 month ago, patient noticed a nodule over her L thigh.  2 weeks ago, she noticed worsening nodules on her R shoulder, neck and face.  Lesions are not painful and do not itch.  No purulent discharge.  She has not had a similar rash in the past.  She denies fevers or chills.  During the last month, the patient has also noted a sore throat with associated cough that did not improve with prescribed antibiotics from PMD.  She has had recent daily headaches associated with photophobia, and relieved with resting in a dark room.  She has had nausea and four episodes of emesis on the day of admission.  Last travel was to Las Vegas 1 month ago to visit family.  No pets at home.  Lives with her husband, daughter and granddaughter.  No sick contacts.  Home medications include tacrolimus, mycofenolate mofetil, prednisone, Bactrim, valacyclovir and amlodipine. 

Vitals: T 37.1, HR 120, RR 18, BP 129/72, O2 sat 98% on RA

Physical Exam significant for A&Ox4, +light sensitivity, clear cardiac and pulm exam and skin with multiple erythematous, flesh colored papules and nodules with central, partly necrotic umbilication over neck, face, shoulders and thigh

CBC: WBC 1.48> Hb 10.7/Hct 34.7 <Plt 296 (MCV 88.1, RDW 15.8%)

CMP:

Na 134/K 5.0/Cl 102/HCO3 18/BUN 47/Cr 2.37 <Glucose 98(Baseline Cr: 1.5-1.7)

ALP 57>T.protein 6.6/Albumin 3.3/AST 17/ALT 17/Tbili 0.2

Ca 10, Mg 2.0, Phos 3.6

Coags: PT 16.2, INR 1.3, PTT 34.3

Renal transplant workup:

  • Tacrolimus level: 7.4 ng/mL (normal 5-20)
  • UA: 50 protein, neg leuk/nitrite, neg blood
  • FeNa: 3.9%, FeUrea: 45.4%
  • Uprotein/cr: 0.3

Infectious workup initiated with the following findings:

  • Serum CMV, HSV, JC Virus and BK Virus not detected
  • BCx: initially negative but after 4 days grew yeast, speciating to cryptococcus
  • Serum Crypto Ag titer: >1:2560
  • CTH: negative for mass effect or hemorrhage
  • LP performed with the findings:
    • Opening Pressure 13
    • RBC 2000
    • WBC 2
    • Glucose 46
    • Protein 38
    • CSF Culture: Cryptococcus neoformans, titer 1:80
  • CXR and CT Chest done which showed b/l scattered pulmonary nodules, and large are of patchy LLL airspace disease with evidence of central necrosis and cavitation

Skin biopsy done: cutaneous cryptococcus.

Treatment: Patient started on amphotericin and flucytosine for disseminated cryptococcus.  Multiple LPs done due to persistent headaches.  Headache resolved by day 12 and she was discharged home with daily fluconazole as maintenance therapy.

Teaching points:

  1. Cryptococcus is an environmental fungus found in the soil, trees and bird droppings. Third most common invasive fungal infection in solid organ transplant recipients (median time of onset is 16-21 months post-transplant).
  2. Symptoms of cryptococcal infections in solid organ recipients: meningitis, pulmonary infection, cutaneous (cellulitis, papular, nodular, ulcerative, majority on lower extremities)
  3. Treatment: manage ICP, antifungal therapy with amphotericin B + flucytosine x2 weeks followed by fluconazole maintenance for 6-12months. Reduce immunosuppression if possible.

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