SESSION TYPE: Infectious Disease Student/Resident Case Report Posters I
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Chronic glucocorticoid use predisposes to infections by impairing host cell-mediated immunity and by impairing phagocytes ability to reach the site of infection. We report a case of pulmonary nocardiosis followed by cryptococcal meningitis in a patient on chronic corticosteroid therapy for treatment of Evan's syndrome.
CASE PRESENTATION: An 80 year old male with a history of Evan's syndrome maintained on 40 mg daily of prednisone (3 months) presented with malaise and fatigue. One month prior, he presented with shortness of breath and was diagnosed with Nocardia asteroides nodulocavitary pneumonia. During that hospitalization, bronchoscopy with lavage was performed; gram stain revealed beaded, filamentous gram-positive rods that were modified Acid Fast Bacilli stain positive. He was empirically treated for nocardiosis with linezolid and trimethoprim-sulfamethoxazole. Contrast enhanced computerized tomography (CT) scan of the brain was negative for abscess. Upon readmission for generalized weakness, progressive nocardiosis was initially suspected. However, repeat CT of the thorax showed marked improvement. RNA PCR for HIV was negative. As part of his evaluation, blood cultures were sent despite the absence of fever, which began growing germ tube negative yeast. Serum cryptococcal antigen was positive at a titer of 1:8. He was started on intravenous fluconazole and a lumbar puncture was performed. Cerebrospinal fluid revealed a WBC count of 173 cells/mm3(82% lymphocytes), glucose of 66 mg/dl and a protein of 409 mg/dl. CSF cryptococcal antigen returned positive at a titer of 1: 2; CSF fungal cultures failed to grow. His blood cultures grew Cryptococcus neoformans. His treatment regimen was switched to liposomal amphotericin B and oral flucytosine. He improved and completed a 14 day induction course, was discharged on consolidation fluconazole, trimethoprim-sulfamethoxazole (in the interim N. asteroides TMP-SMX sensitivity was confirmed by a reference laboratory) and prednisone taper.
DISCUSSION: Corticosteroid use is associated with up to 30% of cases of cryptococcal infection in persons who are HIV-negative.  Cryptococcosis is most often seen in the United States in patients with advanced HIV infection, but a number of other conditions confer a predisposition to cryptococcal infection, including idiopathic CD4 lymphocytopenia, transplantation, connective-tissue disease, malignant tumors, glucocorticoid therapy, chronic obstructive pulmonary disease, cirrhosis, and sarcoidosis.
CONCLUSIONS: Chronic corticosteroid treatment increases susceptibility to a variety of infections. Physicians should have a high index of suspicion for opportunistic infections in patients on corticosteroids presenting with atypical symptoms.
1) Pappas PG, Perfect JR, Cloud GA, et al. Cryptococcosis in human immunodeficiency virus-negative patients in the era of effective azole therapy. Clin Infect Dis 2001;33:690-699
DISCLOSURE: The following authors have nothing to disclose: Nayan Desai, Shipali Pulimamidi, Matthew Grant, Anuradha Mookerjee
No Product/Research Disclosure InformationCooper University Hospital, UMDNJ, Camden, NJ