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Chest Infections |

A Wheeze and a Whisper

Michael Sanley, MD; Anne O'Donnell, MD; Christine Fleury, MD
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Pulmonary, Critical Care, and Sleep Medicine, MedStar Georgetown University Hospital, Washington, DC


Chest. 2014;146(4_MeetingAbstracts):133A. doi:10.1378/chest.1993034
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Abstract

SESSION TITLE: Infectious Disease Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Pulmonary cryptococcosis is rare complication of immunocompromised individuals typically presenting as pulmonary nodules or consolidation seen on chest imaging.1 We present a case of ulcerative endobronchial cryptococcosis without parenchymal involvement.

CASE PRESENTATION: A 44 year-old female with juvenile rheumatoid arthritis, allergic rhinitis and gastroesophageal reflux, presented to clinic for evaluation of severe persistent asthma, productive cough, and hoarseness. Medications included methotrexate, etanercept, prednisone 4mg, fluticasone-salmeterol, budesonide, montelukast, and levalbuterol. ENT evaluation revealed vocal cord swelling, thrush, and steroid laryngitis. She received multiple courses of antibiotics, fluconazole, and increasing doses of systemic steroids. Her etancercept was discontinued and she was maintained on methotrexate. Despite escalating asthma therapy, her symptoms worsened and her voice reduced to a whisper. Imaging revealed subglottic narrowing and tracheal ulcerations. Bronchoscopy revealed diffuse white plaques with ulcerations throughout the trachea, right mainstem bronchus, and bronchus intermedius. Endobronchial biopsy revealed Cryptococcus neoformans. Lumbar puncture was negative for Cryptococcus. She was started on amphotericin B and transitioned to oral fluconazole at 400mg daily. She has shown improvement in follow-up with resolution of her asthma symptoms and improvement in her voice.

DISCUSSION: Cryptococcosis is caused by the inhalation of the spores of Cryptococcus. Pulmonary symptoms are often absent or non-specific and pure endobronchial involvement is rare.2 Our patient’s immunocompromised status due to high-dose prednisone, etanercept, and high doses of inhaled steroids likely predisposed her to a tracheal infection. While infrequently presenting as solitary bronchial mass lesions, to our knowledge, diffuse tracheal cryptococcal ulceration has only one other isolated case report.3

CONCLUSIONS: Diffuse crytpococcal tracheal infections, though rare, should be considered in an immunocompromised patient with progressive, refractory airway symptoms.

Reference #1: Chang WC et al. Pulmonary cryptococcosis: comparison of clinical and radiographic characteristics in immunocompetent and immunocompromised patients. Chest 2006; 129(2): 333-340.

Reference #2: Sahoo D et al. Endobronchial cryptococcosis. J Bronchol 2005; 12(4): 236-238.

Reference #3: Inoue Y et al. Pulmonary cryptococcosis presenting as endobronchial lesions in a patient under corticosteroid treatment. Intern Med 2007; 46(8):519-23.

DISCLOSURE: The following authors have nothing to disclose: Michael Sanley, Anne O'Donnell, Christine Fleury

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