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• W2895535232 abstract "SESSION TITLE: Critical Care 4 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Cryptococcus is an encapsulated yeast found in bird droppings. Transmission occurs via inhalation of spores into the lungs. Whereas most infections cause symptoms ranging from asymptomatic to pneumonia-like, disseminated Cryptococcus (DC) presents most often with severe pneumonia and meningitis. DC is primarily seen in immunocompromised patients with HIV or immunosuppression (post-transplant, cancer, chemotherapy, autoimmune disease), and is rarely seen in the immunocompetent patient. CASE PRESENTATION: 84 year old woman with past medical history of CHF, COPD, atrial fibrillation, hypothyroidism, diabetes and CVA with resultant tracheostomy (chronically on a ventilator) and PEG tube who presented with hypoxia. Patient also had a history of Pseudomonal pneumonia/sepsis and carbapenem-resistant Enterobacter. The patient was nonverbal and had no family at bedside. The only history was from a nursing home packet. It said she had a SpO2 around 80% and was more short of breath than usual. In the ED, she was on minimal ventilatory settings. Initial vitals: BP 123/61, HR 95, SpO2 95% on FiO2 40%, RR 22, T 96.1F. Initial labs were pertinent for a reactive leukocytosis, influenza A/B and RSV negative, and HIV 1/2 Ab negative. Blood cultures were also taken. CXR showed hazy opacity over right hemithorax, moderate-sized left pleural effusion, and probable pulmonary vascular congestion bilaterally. Patient was started on cefepime, azithromycin and vancomycin for sepsis, and sent to the ICU. The patient became hemodynamically unstable, requiring pressors, and developed seizures. CT of the head showed extensive encephalomalacia involving both MCA territories, likely representing chronic infection, and she was started on antiepileptics. Preliminary blood cultures grew yeast and capsofungin was started for presumed candidemia; capsofungin was changed to liposomal amphotericin after histological confirmation of Cryptococcus. Eventually multiple blood cultures speciated Cryptococcus neoformans; serum cryptococcal Ag was positive and quantification >1:2560. Goals of care were eventually discussed with the family, and the patient was transitioned to hospice with antibiotic treatment and no pressors. She passed away soon after arrival. DISCUSSION: Disseminated Crytpococcus following pulmonary infection has a poor prognosis. In fact, DC central nervous system involvement – presenting with seizures, headache, altered mental status, etc. – is thought to be due to impaired cell-mediated immunity; the mortality rate is about 20% in immunosuppressed patients. Rarely is DC seen in immunocompetent patients, and if so, it is usually C. gattii. CONCLUSIONS: Although our patient had a chronic ventilator and multiple morbidities, she was able to mount an appropriate immune response at the onset of infection. Her immunocompetent state suggests that other factors, such as age and co-morbidities, predispose such patients to DC. Reference #1: Aguiar, P. A. D. F., Pedroso, R. D. S., Borges, A. S., Moreira, T. A., Araujo, L. B., & Roder, D. V. D. B. (2017). The epidemiology of cryptococcosis and the characterization of cryptococcus neoformans isolated in a brazilian university hospital. Revista do Instituto De Medicina Tropical De Sao Paulo, 59, e13-9946201759013. S0036-46652017005000208 [pii] Reference #2: Dromer, F., Mathoulin-Pelissier, S., Launay, O., Lortholary, O., & French Cryptococcosis Study Group. (2007). Determinants of disease presentation and outcome during cryptococcosis: The CryptoA/D study. PLoS Medicine, 4(2), e21. 06-PLME-RA-0445R3 [pii] Reference #3: Henao-Martinez, A. F., Gross, L., Mcnair, B., McCollister, B., DeSanto, K., Montoya, J. G., Beckham, J. D. (2016). Risk factors for cryptococcal meningitis: A single united states center experience. Mycopathologia, 181(11-12), 807-814. 10.1007/s11046-016-0048-x [doi] DISCLOSURES: No relevant relationships by Lindsay Hammons, source=Web Response No relevant relationships by Young Im Lee, source=Web Response" @default.
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• W2895535232 date "2018-10-01" @default.
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• W2895535232 title "DISSEMINATED CRYPTOCOCCUS IN AN IMMUNOCOMPETENT PATIENT" @default.
• W2895535232 doi "https://doi.org/10.1016/j.chest.2018.08.256" @default.
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