A 33-year-old man with AIDS presented to the emergency department with fever, dyspnea, cough, and pleuritic chest pain of 3 days’ duration. He had had a Pneumocystis carinii infection 3 years before recently emigrating from the Dominican Republic to the United States. Promiscuous sexual activity was his only risk factor for HIV infection. The patient did not take antiretroviral medications or protease inhibitors because of their cost. Dr Gopi Rana-Mukkavilli of New York City writes that the patient’s CD4+ count was 68 cells/μL. A chest x-ray film demonstrated bilateral interstitial infiltrates. Trimethoprim-sulfamethoxazole and prednisone for Pcariniipneumonia were initiated. The patient continued to spike fevers. Bacterial and fungal cultures of specimens obtained during bronchoscopy yielded Cryptococcus neoformans. The patient’s serum cryptococcal antigen level was elevated. Subsequently, a lumbar puncture was performed to rule out cryptococcal meningitis. Microscopic examination of India ink–stained cerebrospinal fluid revealed budding yeast cells with surrounding capsules consistent with C neoformans meningitis. Cryptococcosis—a systemic mycosis that most often involves the CNS and the lungs—commonly affects immunocompromised persons who have HIV disease and a low CD4+ count. The fungal infection is usually acquired by inhalation of aerosolized spores from pigeon droppings. This patient’s presentation was unusual in that the first symptoms involved the lungs; the CNS manifestations were incidental findings. Often, pulmonary cryptococcosis is difficult to diagnose; the yield from sputum cultures is low, and a bronchoscopy or an open lung biopsy may be needed to obtain tissue that will demonstrate the pathogen. Because cryptococcal meningitis in patients with AIDS can be refractory and is associated with a 50% relapse rate when treatment is discontinued, lifelong maintenance therapy is required. The outcome for persons with disseminated cryptococcosis is poor; mortality approaches 30% for immunocompromised patients with AIDS. Intravenous liposomal amphotericin B was given for 4 weeks, followed by oral fluconazole for lifelong maintenance therapy. The patient is compliant with his medication regimen. FOR MORE INFORMATION:
- Chuck SL, Sande MA. Infections with Cryptococcus neoformans in the acquired immunodeficiency syndrome. N Engl J Med. 1989;321:794-799.