Case Presentation: An 86-year-old woman with a history of COVID-19 and MRSA pneumonia six months prior to presentation and COPD, presented to a local emergency room for abdominal pain related to persistent cough. Other pertinent history included ovarian cancer cured 20 years ago and exposure to tuberculosis when the patient was younger. Computed tomography (CT) of chest, abdomen and pelvis was notable for a 2 cm-sized irregular subpleural nodule on right upper lobe as well as faint ground glass opacities in left lower lobe (image 1). This mass was not present on a prior CT six months ago. The patient was discharged from Emergency Department with close outpatient follow up arranged with Oncology. Patient underwent transbronchial biopsy of the mass and bronchoalveolar lavage (BAL) testing which did not show infection or malignancy. AFB stain and AFB cultures of BAL fluid were negative. Fungal serology for Histoplasma, Blastomycosis, Aspergillus and Coccidiosis were negative. PET-CT found increased activity in the mass. A follow-up CT three months later showed no change in the size of the mass. The patient then underwent CT-guided biopsy of the mass and the histopathologic exam showed presence of Cryptococcus.The patient ended up presenting to the emergency room due to worsening cough and dyspnea before further workup and treatment were initiated. On presentation, she had low grade temperature, tachypnea and worsened hypoxia from her baseline. She had an elevated serum cryptococcal antigen titer of 1:20. Her HIV test was negative. She hadn’t used any systemic steroids in over six months. The patient was started on a loading dose of fluconazole followed by daily dosing for cryptococcal pneumonia. Infectious disease team suggested no lumbar puncture given immunocompetent patient with low cryptococcal titers and absence of central nervous system signs. Patient was planned for treatment for 6 to 12 months with fluconazole. Her hospital course was complicated by prolonged dyspnea. The patient was discharged home on hospital day 18.
Discussion: Cryptococcus species are ubiquitous and respiratory tract is the main portal of entry. We usually think about Crytpococcus as an opportunistic pathogen affecting HIV/AIDS and severely immunocompromised patients; however, it can also affect seemingly immunocompetent individuals. Central nervous system and lungs are the main site of infection. When infected, the symptoms and severity vary significantly from asymptomatic to life-threatening. The management of Cryptococcal pneumonia is an important topic for hospitalists because it can be so different from Cryptococcal meningitis. Mild-to-moderate Cryptococcal pneumonia can be treatable with oral fluconazole for 6 months and longer, but severe cases, such as disseminated or CNS involvement, should be treated similar to Cryptococcal meningitis. The Infectious Disease Society of America Guideline suggests avoidance of lumbar puncture when the patient is not immunocompromised, without CNS symptoms and with low or negative serum cryptococcal antigen titers (note: titer of 1:512 is considered high burden).
Conclusions: Cryptococcal pneumonia is a diagnostic and therapeutic challenge. Hospitalists need to be aware of it as a differential for pneumonia and lung nodule as well as differentiate mild-to-moderate from severe Cryptococcal pneumonia. The decision on lumbar puncture in the absence of apparent CNS symptoms/disseminated diseases is a clinical decision and should be determined on an individual case basis.
