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• W4387249701 abstract "SESSION TITLE: Critical Care Case Report Posters 57 SESSION TYPE: Case Report Posters PRESENTED ON: 10/11/2023 12:00 pm - 12:45 pm INTRODUCTION: COVID-19 causes dysregulated immune response associated with invasive fungal infections like pulmonary aspergillosis, nasal mucor mycosis, candidiasis, cryptococcal meningitis is a rarely reported fungal manifestation. We present a case of a 63-year-old male with altered mentation due to COVID-19 and its treatment-related adverse effects. CASE PRESENTATION: 63-year-old male with a past medical history of follicular lymphoma treated with immunotherapy 3 years prior and currently in remission presented to the ER with altered mental status ongoing for 3 weeks. In the recent past he suffered from severe COVID infection which included 7 weeks stay in the ICU and the hospital, and treatment with high dose steroids up to 80 mg dexamethasone daily followed by a prolong taper. 3 weeks prior to this presentation patient was worked up for the lethargy and urinary incontinence during which MRI brain revealed acute stroke in anterior and posterior circulation and he was initiated on aspirin and discharged to a rehabilitation center. Despite rehabilitation services, patient continued to worsen with new onset of fluctuating mentation, visual hallucinations, and vomiting. Keeping a broad list of differentials including new stroke, hemorrhagic conversion of stroke or cranial metastasis of lymphoma patient was readmitted and MRI brain revealed small acute infarct in corpus callosum but these findings were inconsistent with patient's presentation. On admission, patient was afebrile, HR was 100/minute, normotensive and saturation 98% on room air. Neurologic exam was significant for aphasia, alert and oriented to self, upper and lower extremity strength 5/5, normal sensory exam and diffusely reduced bulk and tone on exam. Blood work grossly remarkable with no leukocytosis, hemoglobin of 10.8 g/dl, platelet count of 71,000 which was chronic, and normal electrolytes. Lumbar puncture was done which revealed an opening pressure of 26 mm of water, CSF studies revealed glucose of 18mg/dl (serum glucose of 128mg/dl), leukocyte count of 355/uL, red cell count of 24/uL and <4mg/dl protein. CSF cryptococcal antigen was positive and gram stain showed few cryptococcus neoformans. CSF fungal culture/India ink identified yeast as the cryptococcus neoformans. Treatment for the induction phase initiated with Amphotericin B and flucytosine for 2 weeks, repeat lumbar puncture at 2 weeks was sterile and patient was transitioned to therapeutic dose of fluconazole for 10 weeks followed by maintenance dose for 12 months. Patient showed remarkable improvement within the first week of induction phase of treatment. DISCUSSION: The reported incidence of cryptococcosis following COVID-19 is as low as 0.022% with lungs more commonly affected than brain. The major risk factors were mechanical ventilated patients, elderly, ICU admissions, treatment with Tocilizumab, and steroids. The mechanism of cryptococcosis infection following SARS-Cov-2 is multifactorial including COVID induced lymphopenia, immunomodulatory mediated reactivation, vomocytosis of Cryptococcus spp. Early suspicion and prompt treatment is prudent for reduction in morbidity and mortality. CONCLUSIONS: Identified as CACI (COVID-19 associated Cryptococcal Infection), is primarily seen in patient receiving corticosteroid therapy and are admitted to the ICU. A high suspicion of opportunistic infections should be kept in patients discharged from hospital on a prolonged steroid taper. REFERENCE #1: Chastain, DB, Kung, VM, Golpayegany, S, et al.. Cryptococcosis among hospitalised patients with COVID-19: A multicentre research network study. Mycoses. 2022; 65: 815- 823. REFERENCE #2: Regalla D, VanNatta M, Alam M, Malek AE. COVID-19-associated Cryptococcus infection (CACI): a review of literature and clinical pearls. Infection. 2022 Aug;50(4):1007-1012. doi: 10.1007/s15010-022-01805-y. Epub 2022 Mar 24. PMID: 35322336; PMCID: PMC8942802. REFERENCE #3: Rovina N, Koukaki E, Romanou V, Ampelioti S, Loverdos K, Chantziara V, Koutsoukou A, Dimopoulos G. Fungal Infections in Critically Ill COVID-19 Patients: Inevitabile Malum. J Clin Med. 2022 Apr 4;11(7):2017. doi: 10.3390/jcm11072017. PMID: 35407625; PMCID: PMC8999371. DISCLOSURES: No relevant relationships by Cecilia Fumberg No relevant relationships by Maryam Hussain No relevant relationships by Trishna Kattel No relevant relationships by Aanchal Sawhney" @default.
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• W4387249701 date "2023-10-01" @default.
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• W4387249701 title "CACI: A NEW CAUSE TO LOOK OUT FOR IN PATIENTS WITH ALTERED MENTATION" @default.
• W4387249701 doi "https://doi.org/10.1016/j.chest.2023.07.1045" @default.
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