SESSION TITLE: Infectious Disease Student/Resident Cases
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 07:30 AM - 08:30 AM
INTRODUCTION: Cryptococcus neoformans (C. neoformans) can cause potentially life threatening infections in an immunocompromised host, commonly patients on long term steroids, HIV and transplant recipients.
CASE PRESENTATION: 44 year old man presented to emergency department with cough and severe right sided chest pain for 3 days, worsened with cough and deep inspiration. His past medical history included Psoriasis on adalimumab 40 mg every 2 weeks for three years, type 1 diabetes with neurogenic bladder. He denied having fever, chills, rigors, or similar episodes in the past. He lived in a basement apartment, denied any exposure to mold or birds. His vital signs were unremarkable on admission. His examination revealed crackles on the right side of chest. Subsequent computed tomography (CT) showed right middle lobe infiltrate extending to the right pleural margin, hilar lymphadenopathy and prominent mediastinal lymph nodes (Fig 1). He was started on antibiotics for community acquired Pneumonia with atypical coverage. He had negative mantoux test one week prior to admission. Bronchoscopy and bronchoalveolar lavage (BAL) were performed for further evaluation. Antibodies for histoplasmosis and coccidiomycosis were also negative. He was discharged home with azithromycin 500 mg for 5 days as he showed improvement. After 2 weeks fungal cultures from BAL was positive for C. neoformans. He was readmitted and started on intravenous fluconazole 400mg for 4 days. CSF analysis for cryptococcal antigen was negative. He was discharged on oral fluconazole 400 mg daily for 6 months. Subsequent CT chest (Fig 2) after 6 months revealed clearance of right middle lobe infiltrate.
DISCUSSION: Cryptococcal infections have been reported with the use of TNF-α antagonists other than Adalimumab (infliximab or etanercept) in the FDA Adverse Event Reporting System from 1998 - 2002. Post marketing data's for adalimumab revealed no cryptococcosis infections in 10,050 treated patients in the USA. Adalimumab is a recombinant human IgG1 monoclonal antibody that binds to human TNF alpha with high affinity, both impairing cytokine binding to its receptors and lysing cells that express TFN-α on their surface. C. neoformans relies on effective T-cell host defenses. TNF-α is involved in maintaining an immune response of T-helper cell type 1 by producing interleukin-12 (IL-12) and IL-18, with subsequent production of fungicidal interferon-γ. To our knowledge this is the third reported case of adalimumab associated with Cryptococcus Pneumonia.
CONCLUSIONS: Further studies are needed to prove relationship of TFN-α antagonist and C. neoformans. As the infection was caught early before a systemic and CNS involvement, patient was successfully treated. Timely diagnosis is prudent to avoid life threatening C.neoformans infections.
Reference #1: Iwata T1, Nagano T. Adalimumab-associated pulmonary cryptococcosis. Ann Thorac Cardiovasc Surg. 2011;17(4):390-3.
DISCLOSURE: The following authors have nothing to disclose: Wajahat Lodhi, Nirosshan Thiruchelvam, Shraddha Narechania, K.v Gopalakrishna
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