SESSION TITLE: Infectious Disease Cases I
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Sunday, October 26, 2014 at 10:45 AM - 12:00 PM
INTRODUCTION: Cardiac Cryptococcal involvement is seen almost exclusively in HIV infection. We report an HIV negative patient with Cryptococcal pericarditis in the setting of dissemination and metastatic cancer.
CASE PRESENTATION: A 66 year-old-man with widely metastatic prostate cancer treated with leuprolide, docetaxel, prednisone and carboplatin presented with malaise and disorientation. Initial exam revealed 95% O2 saturation on room air, cachexia, decreased L-sided breath sounds, and disorientation. Labs documented anemia, hyponatremia and funguria. CT head showed no acute changes. CT chest showed moderate R and small L-sided effusions, LUL opacities, LLL mass with consolidation and a pericardial effusion (Fig.1). He developed hypoxemic, hypercapnic respiratory failure. He received broad-spectrum antibiotics and bilevel, non-invasive ventilator support. CSF showed 28 WBC, 98% PMN, protein 82.9 mg/dl, normal glucose but positive India ink, suggesting Cryptococcal infection. Amphotericin B and flucytosine were added. Cryptococcal titer was 1:64 in both blood and CSF. Pericardial, pleural, cerebrospinal fluid and urine all later grew Cryptococcus neoformans. Despite therapy, mental status declined, comfort care was instituted, and he expired.
DISCUSSION: Disseminated Cryptococcus neoformans occurs in immunosuppressed patients such as HIV, on immunosuppressive medications, or chronic diseases such as cirrhosis or diabetes. Meningoenecephalitis and pulmonary infiltrates are the most common manifestations. Pleural and pericardial involvement are unusual. Cryptococcal pericarditis has been reported rarely in HIV patients, and in the non-HIV population, in a single patients with Hodgkin’s disease1, after lung transplantation2, or diabetes3.
CONCLUSIONS: Extra-pulmonary Cryptococcal disease has a high mortality rate. Individuals living with relative immunosuppression may be at risk for this disease. Cryptococcal disease should be considered a possible etiology for such patients with pericardial and/or pleural effusions.
Reference #1: Charles P Duvall et al. Cryptococcus neoformans pericarditis associated with Hodgkin’s disease. Annals of Int med 1966;64:850-856
Reference #2: Levy PY, et al. Pericardial effusion due to Cryptococcus neoformans in a patient with cystic fibrosis following lung transplantation. Int J Infect Dis 2008;4:452
Reference #3: Chen, Mei-Yin and Chi-Wei Tao. Disseminated Cryptococcosis in a HIV-Negative Patient Initially Presenting As Bilateral Massive Pleural Effusion: A Case Report & Literature Review. Thoracic 28 (3) 2013: 186-191
DISCLOSURE: The following authors have nothing to disclose: Norma Ramey, H. Ari Jaffe
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