Case Presentation: A 77-year-old woman with a significant health history including metabolic syndrome, chronic obstructive pulmonary disease, ischemic cardiomyopathy, stage III chronic kidney disease and a recently diagnosed SARS-CoV-2 infection. She presented with sepsis and cardiorenal syndrome. On arrival, she was in acute respiratory distress with severe metabolic and respiratory acidosis, and in oliguric state, not responding to high dose of furosemide. She was placed on mechanical ventilation and started on hemodialysis. She was treated with Remdesevir, convalescent plasma for SARS-CoV-2 and glucocorticoids for cytokine storm. Her blood cultures also grew enterococcus, requiring antibiotics complicated later by C-diff colitis. Also, she developed ventilator associated pseudomonal pneumonia, which improved with antibiotics. Following improvement, when her sedation was discontinued to initiate weaning trials, she continued to remain unresponsive. CT Head revealed no evidence of stroke. Lumbar puncture demonstrated 4 WBC/cumm(low), 17 RBC/cumm, glucose of 86mg/dl and total protein of 54mg/dl with culture growing cryptococcal neoformans. She was started on Fluconazole but given her poor prognosis, she was compassionately extubated.
Discussion: Cryptococcal meningoencephalitis is an opportunistic infection mostly seen in HIV patients. Other risk factors include treatment with glucocorticoids or immunosuppressive agents as seen in transplant patients. The diagnosis is challenging due to its subacute presentation, and a high index of suspicion is required. Lumbar puncture and serology confirm the diagnosis, and a CSF WBC count <20cells is a poor prognostic factor. With the advent of SARS-CoV-2, there have been numerous reports of fungal superinfections, especially Aspergillus. This case is being reported to create awareness and help with early diagnosis of Cryptococcal superinfection in the SARS-CoV-2 pandemic.
Conclusions: SARS-CoV-2 infections can present in many unusual ways, and the pandemic has overwhelmed the world’s healthcare systems. The virus continues to challenge us with atypical presentations and complications. There is increasing evidence of fungal superinfections, mostly Aspergillus pneumonia worldwide. Cryptococcal meningoencephalitis superinfection requires high clinical suspicion in critically-ill patients diagnosed SARS-CoV-2 infection.