Case Presentation: A 75 y.o. M with pertinent medical conditions that include basal cell carcinoma and melanoma of Tibia s/p surgical resection, urothelial carcinoma s/p chemotherapy and urological bladder reconstruction presented to the Hematology Oncology ward with a 6 week history of persistent back pain, fatigue, and unintentional weight loss. Physical exam revealed thoracic spinal tenderness and pain with passive and active range of motion of bilateral lower extremities. Based on patients medical history and physical exam, spinal X-rays were obtained which revealed a T8 vertebral fracture. With high suspicion for metastatic disease, IR was consulted and completed a bone biopsy followed by vertebroplasty. Bone biopsy was concerning for lymphoma but not definitive therefore, whole body PET scan was obtained while inpatient. Patients PET scan revealed diffuse uptake in bilateral tibial plateaus and multiple lesions in the thoracic cavity and spine concerning for metastatic lymphoma. Patient at this time underwent 4 bone biopsies and 2 VATS procedures with 14 total tissue biopsies of different thoracic lesions without any definitive diagnosis. After a 28 day stay, patient and his family did not have a diagnosis and was clinically deteriorating. It was at this time that the treatment team re-visited possible infectious etiologies and sent off tissue samples to pathology for invasive fungal infection staining. Fungal stains revealed broad based budding yeast in multiple thoracic cavity biopsies and by that night patients serum Cryptococcal antigen was detected in the patients serum. Patient was diagnosed with disseminated Cryptococcal infection and was started on treatment immediately. Unfortunately, due to complications from pain control, patient experienced a life threatening bowel obstruction and was made comfort care before he passed away.
Discussion: As medical therapies like chemotherapy and immunosuppressants advance, the number invasive fungal infections (IFI) are on the rise. Major risk factors for IFI include neutropenia, malignancy, previous exposure to chemotherapy, bone marrow/solid organ transplants, prolonged corticosteroid use, and HIV infection. Other co-morbidities linked to IFI are diabetes, COPD, and autoimmune diseases present in a majority of hospitalized patients.
Conclusions: 3 out of every 4 patients with IFI will become hospitalized making the identification and treatment of these types of diagnosis important to the practicing Hospitalist. It is important to note that there is a 30% mortality associated with IFI at 1 year and ~30% occurrence in patients while hospitalized in the ICU. By avoiding anchoring bias and keeping a differential broad in a clinically deteriorating patient, a more timely diagnosis in this patient may have prevented death, an important lesson learned on the wards.