Chest Infections: Student/Resident Case Report Poster - Chest Infections I |

Cryptococcal Pneumonia and Bacteremia in a Post-Partum Female With Systemic Lupus Erythematous FREE TO VIEW

Elizabeth Sonntag, MD; James Pellerin, MD
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Virginia Commonwealth University, Richmond, VA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):174A. doi:10.1016/j.chest.2016.08.183
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SESSION TITLE: Student/Resident Case Report Poster - Chest Infections I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Cryptococcal pneumonia is a rare disease that can mimic bacterial pneumonia.

CASE PRESENTATION: A 24-year-old Caucasian female with a history of systemic lupus erythematous complicated by lupus nephritis (on azathioprine, hydroxychloroquine and low dose prednisone) and recent parturition presented with one month of dyspnea, productive cough, and fever. Initial exam revealed an afebrile, tachycardic and tachypneic woman with a systolic murmur. Work up revealed acute on chronic renal failure, metabolic acidosis, and a right lower lobe infiltrate on chest radiograph. She was admitted to the intensive care unit and started on broad spectrum antibiotics for presumed health care associated pneumonia, and started on hemodialysis for renal failure. Chest computed tomography showed groundglass and nodular consolidative opacities in a bronchovascular distribution in the right middle lobe and lung bases, as well as scattered subcentimeter nodules particularly in the right lung base. On the fourth day of hospitalization her blood cultures returned positive for yeast, which speciated to Cryptococcus neoformans. Cryptococcus blood antigen was also positive. She was started on liposomal amphotericin B and flucytosine and immunosuppression was discontinued. Lumbar puncture results were normal. Transesophageal echocardiogram showed an echodensity on the mitral valve, which was felt to represent early sclerosis, rather than fungal endocarditis. She was ultimately discharged on a two-week course of liposomal amphotericin B plus flucytosine, followed by a prolonged course of fluconazole and minimization of immunosuppression.

DISCUSSION: Providers should remain vigilant when caring for immunosuppressed patients who present with pulmonary infiltrates and keep Cryptococcal pneumonia in their differential diagnosis. Cryptococcus neoformans pulmonary infection occurs through inhalation of spores (most common), inhalation of conidia, reactivation of latent infection, or hematogenous dissemination1. Individuals with defective cell-mediated immunity such as HIV-AIDS, organ transplantation, hematologic malignancy, or chronic corticosteroid therapy develop the most serious manifestations, such as cerebro-meningeal or pulmonary infection. Pregnancy is a time of relative immunosuppression in which there is diminished cell-mediated immunity2.

CONCLUSIONS: This patient presented with characteristic symptoms and imaging findings of community acquired pneumonia, however was ultimately diagnosed with Cryptococcal pneumonia and bacteremia after blood cultures from admission incidentally isolated Cryptococcus neoformans. This infection was likely due to iatrogenic immunosuppression from medication as well as her recent pregnancy.

Reference #1: Parker, Mark S., and Melissa L. Christenson. Chest Imaging Case Atlas. 2nd ed. New York: Thieme, 2012. 328-330. Print.

Reference #2: Ely EW, Peacock JE Jr, Haponik EF, Washburn RG. Cryptococcal pneumonia complicating pregnancy. Medicine (Baltimore) 1998; 77:153.

DISCLOSURE: The following authors have nothing to disclose: Elizabeth Sonntag, James Pellerin

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