Today Dr. Cohen described a case where a patient was ultimately found to have dissemintated cryptococcus with meningoencephalitis with signs and symptoms of pulmonary cryoptococcus and potentially osteoauricular and skin involvement (albeit not proven).
Remember that cryptococcus is an ubiquitous yeast that is inhaled and leads to primary pulmonary infection. It is typically contained but when patients are immunosuppressed, it can reactivate and result in dissemintated disease. Risk factors for disseminated disease are: HIV/AIDS, solid organ transplant, glucocorticoid use, diabetes, liver diease and kidney injury. According to a 2008 article in European Journal of Clinical Microbiology & Infectious Disease by Baddley et.al, that looked at a restrospective chart review of 15 medical centers from 1990-2000 in HIV negative patients with pulmonary cryptococcosis, they found that high dose corticosteroid use (great than or equal to prednisone 20mg daily for 60 days) had an odds ratio of 5.3 in a multivariate analysis of factors associated with disseminated disease. Similarly, headache and altered mental status were 30.4 and 21.7 respectively while fever was 3.2 and weight loss 5.9.
It is a reminder that
- Glucocorticoid use of 20mg per day or more for 60 days or longer is enough to put a patient at risk
- Even in HIV negative patients, routine lumbar puncture is recommended in patients with cryptococcal pneumonia and risk factors for disseminated disease
- In HIV negative patients, the most common radiographic finding of pulmonary cryptococcosis was lobar consolidation or multiple pulmonary noudles (26% and 23% respectively based on the cited study above)
For more information, please see the Blog Post from August 28, 2017 on cryptomeningoencephalitis in a post-transplant patient. The blog also outlines the common CSF and LP findings and links to Dr. Alan Hunter's CSF study guide.