Disseminated Cryptococcosis in an Immunocompromised Patient with Altered Mental Status and a Lung Nodule

Authors

Dena H. Tran, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, 110 South Paca Street, Baltimore, MD 21201, USAFollow
Avelino C. Verceles, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, 110 South Paca Street, Baltimore, MD 21201, USA
Ellen T. Marciniak, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, 110 South Paca Street, Baltimore, MD 21201, USA

Abstract

Introduction: Disseminated cryptococcosis is an opportunistic infection that commonly affects the central nervous and respiratory systems and is often fatal in immunocompromised patients. Diagnosing disseminated cryptococcosis is challenging at times due to the nonspecific presentation, resulting in delayed treatment and increased mortality. Case Presentation: A 48-year-old man presented with altered mental status and shortness of breath requiring intubation. Medical history was significant for rheumatoid arthritis, diabetes mellitus, chronic kidney disease, sarcoidosis, and polymyalgia rheumatica. Home medications included prednisone, methotrexate, and tocilizumab. Computed tomography chest revealed multifocal pneumonia with a cavitary nodule with halo sign. One week after extubation, the patient remained confused. Lumbar puncture (LP) was positive for Cryptococcus neoformans within 5 days. Bronchoalveolar lavage (BAL) yielded similar results on fungal culture one month later. Conclusion: An immunocompromised patient who presents with altered mental status with concomitant lung nodules should have disseminated cryptococcosis as a differential diagnosis. CT chest commonly demonstrate peripheral lung nodules with cavitation, air bronchograms, halo sign, and/or enlarged mediastinal lymphadenopathy, as found in our patient. If the clinical suspicion for disseminated cryptococcosis is high, an LP should be performed, as BAL results may often be delayed since Cryptococcus grows slowly from the lungs. Empiric antifungals should be started immediately, given increased mortality if treatment is delayed.

Recommended Citation

Tran, Dena H.; Verceles, Avelino C.; and Marciniak, Ellen T. (2023) "Disseminated Cryptococcosis in an Immunocompromised Patient with Altered Mental Status and a Lung Nodule," Journal of Community Hospital Internal Medicine Perspectives: Vol. 13: Iss. 2, Article 6.
DOI: 10.55729/2000-9666.1157
Available at: https://scholarlycommons.gbmc.org/jchimp/vol13/iss2/6