Changi General Hospital, Singapore, Singapore
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
SESSION TITLE: Chest Infections II
SESSION TYPE: Case Report Poster
PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM
INTRODUCTION: Cryptococcal infections are well described in immunocompromised patients and are seldom seen in immunocompetent hosts. However, Cryptococcus gattii, a species of the Cryptococcus complex, has been reported to be the causative agent of disseminated cryptococcosis in both immunocompromised and immunocompetent hosts.
CASE PRESENTATION: A 49 year old Chinese gentleman with no known past medical history presented with headache for 1 month with fever and vomiting 2 weeks after. He works at a construction site, does not own any domestic pets and had no significant travel history. There were no neurological deficit nor lung findings clinically. MRI of the brain showed multiple ring enhancing lesions in both cerebral and cerebellar hemispheres. CT scan of the thorax revealed a sizable 6.5 x 4.5 x 4.0cm heterogeneously enhancing lobulated mass in the right upper lobe extending to the hilum. (Image 1) Cryptococcus gatii was cultured from the cerebrospinal and bronchial alveolar lavage showed histological evidence of Cryptococcus. He was started on induction therapy of Amphotericin B 60mg OM and Flucytosine 200mcg Q6H. A dense right mid zone opacification was seen on the plain radiograph at the start of therapy and repeat radiograph 19 days after showed mild interval reduction in the opacification (Image 2). MRI of the brain done 21 days after commencement of therapy showed reduction in sizes of the foci of most of the lesions. He completed 27 days of induction therapy and was discharged well with 3 months of Oral Fluconazole.
DISCUSSION:Cryptococcus gatti causing cryptococcosis emerged in British Columbia in 1999. The most common presentations were respiratory symptoms (76.6%) followed by neurological symptoms (7.8%). Diagnosis can be confirmed by positive C. gatti culture while antigen detection and histopathology makes the diagnosis highly probable. Although fungal infections affect mostly immunocompromised patients, studies show that only 2.9% of those with C. gattii infection were HIV positive. An Australian study observed a 30% case-fatality rate with C. neoformans infection, but no deaths were observed in 20 patients with C. gattii infection. Antifungal treatment can be oralized with clinical improvement. Some studies have shown no serotype susceptibility differences to antifungals for C. neoformans and C. gattii.
CONCLUSIONS:Cryptococcus gattii infections are uncommon but have been reported in several immunocompetent individuals. Prompt recognition and treatment is crucial to reduce morbidity and mortality.
Reference #1: Fyfe M, MacDougall L, Romney M, Starr M, Pearce M, Mak S, et al. Cryptococcus gattii infections on Vancouver Island, British Columbia, Canada: emergence of a tropical fungus in a temperate environment. Can Commun Dis Rep. 2008;34:1-12
Reference #2: Galanis E, MacDougall L Epidemiology of Cryptococcocus gattii, British Columbia, Canada, 1999-2007. Emerg Infect Dis. 2010;16:251-7
DISCLOSURE: The following authors have nothing to disclose: Rosabelle Kang, Jessica Quah, Teck Boon Low, Chester Chong
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