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Disseminated Cryptococcal Lymphadenitis With Negative Cryptococcal Antigen in an Immunosuppressed Patient FREE TO VIEW

John Mikhail, MD; Mohamad Elsawaf, MD; Albert Rojtman, MD; Manimala Roy, MD; Marnie Rosenthal, DO
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Jersey Shore University Medical Center, Neptune, NJ

Chest. 2013;144(4_MeetingAbstracts):244A. doi:10.1378/chest.1702053
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SESSION TITLE: Infectious Disease Student/Resident Case Report Posters II

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Cryptococcal lymphadenitis is a rare, but well-documented, manifestation of cryptococcal infection in transplant patients. Cryptococcal antigen tests are highly sensitive and specific tests for diagnosis. We present a case of a patient with disseminated cryptococcal lymphadenitis in a transplant patient with a negative cryptococcal serum antigen assay.

CASE PRESENTATION: A 46 year-old female with a past medical history of end-stage renal disease on home hemodialysis, type 1 diabetes, hypertension, hyperlipidemia, hypothyroidism, rheumatoid arthritis, failed kidney/pancreatic transplants, currently on immunosuppression, presented with fatigue, generalized weakness, poor appetite, and dyspnea on exertion with a cough for 3 days. She was febrile to 102.4 F, with an elevated creatinine of 9.3 mg/dL, and hemoglobin of 8.3 gm/dL. Chest CT showed a left hilar mass and mediastinal lymphadenopathy, suspicious for malignancy. Blood cultures were positive for Cryptococcus neoformans within 48h and an endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) revealed fungal organisms consistent with Cryptococcus and no evidence of malignancy. She was started on amphotericin B and flucytosine. Tacrolimus was discontinued. Cryptococcal serum antigens were repeatedly negative, and turned only weakly positive with a titer of 1:1. She was continued on hemodialysis 5 days a week and her condition improved. She was eventually discharged on a course of fluconazole after receiving 1 gram Amphotericin B and flucytosine.

DISCUSSION: Cryptococcosis is an opportunistic infection in solid-organ transplant recipients with a reported incidence of 1-5% and mortality of 20-40%. Disseminated cryptococcosis is defined by a positive culture from at least two different sites or positive blood cultures. Disseminated infection, including CNS disease and fungemia, occur in 52-61% and 20-25% of solid organ transplant recipients, respectively. Infection can involve any body site or structure following dissemination, including the liver, peritoneum, urogenital tract, adrenals, eyes and lymph nodes. Cryptococcal serum antigen assays that measure polysaccharide released have proven to be valuable diagnostic tests for cryptococcosis, however is not considered a sensitive test for pulmonary cryptococcosis. Case series have documented patients with disseminated Cryptococcus lymphadenitis and fungemia with negative cryptococcal antigen tests as in our patient.

CONCLUSIONS: Disseminated cryptococcal lymphadenitis can be seen with negative cryptococcal antigen tests. Consider positive blood cultures and EBUS-TBNA with fungal organisms as alternative, and possibly, more specific forms of diagnosis.

Reference #1: Srinivasan R, et al. Cryptococcal lymphadenitis diagnosed by fine needle aspiration cytology: a review of 15 cases. Acta Cytol 2010; 54: 1-4.

DISCLOSURE: The following authors have nothing to disclose: John Mikhail, Mohamad Elsawaf, Albert Rojtman, Manimala Roy, Marnie Rosenthal

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