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P271 A masquerading case of Cryptococcus neoformans

POSTER SESSION 2, SEPTEMBER 22, 2022, 12:30 PM - 1:30 PM:   INTRODUCTION: Cryptococcal infections are commonly seen in immunocompromised hosts, especially HIV-infected patients and patients on immunosuppressive therapy. Cryptococcus shows a strong tropism for the central nervous system however cutan...

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Autores principales: S, Divyashree, Sontakke, Tushar, Kulkarni, Satish, Pandey, Ashok, Thakur, Archana, Debbarman, Panchami, Yadav, Shalini
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Oxford University Press 2022
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9516141/
http://dx.doi.org/10.1093/mmy/myac072.P271
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author S, Divyashree
Sontakke, Tushar
Kulkarni, Satish
Pandey, Ashok
Thakur, Archana
Debbarman, Panchami
Yadav, Shalini
author_facet S, Divyashree
Sontakke, Tushar
Kulkarni, Satish
Pandey, Ashok
Thakur, Archana
Debbarman, Panchami
Yadav, Shalini
author_sort S, Divyashree
collection PubMed
description POSTER SESSION 2, SEPTEMBER 22, 2022, 12:30 PM - 1:30 PM:   INTRODUCTION: Cryptococcal infections are commonly seen in immunocompromised hosts, especially HIV-infected patients and patients on immunosuppressive therapy. Cryptococcus shows a strong tropism for the central nervous system however cutaneous tropism is not uncommon. Here we describe an HIV-negative immunocompromised patient who developed disseminated cryptococcosis with the predominant presentation being painful thigh lesions. CASE DETAILS: A 56-year-old lady presented with skin lesions and burning pain over both thighs for 1 month and a high-grade fever for 15 days. Her thigh lesions were initially treated elsewhere as tinea corporis. Her previous medical history was significant for poorly controlled diabetes, and chronic liver disease (secondary to autoimmune hepatitis or AIH). Her ongoing medications included prednisolone, anti-diabetics, and tenofovir. At presentation, the only significant physical findings were large irregular areas of central hypo-pigmentation with peripheral hyper-pigmentation and superficial small blisters over both thighs. These areas showed signs of inflammation. The empiric antimicrobial therapy included piperacillin-tazobactam and fluconazole (in view of prior urine culture growing Candida species). Over the next 48 h, fever continued, thigh pain worsened and the lesions on thighs blistered with violaceous discoloration. Her blood cultures sent at admission grew Candida kruzei, resistant to fluconazole, sensitive to voriconazole, amphotericin and echinocandins. Beta-D Glucan was also elevated. Fluconazole was discontinued, and anidulafungin was initiated. A repeat culture (prior to the start of anidulafungin) was still positive for C. krusei, but a subsequent blood culture (after the start of anidulafungin) was negative. Echocardiography did not show features of endocarditis. After a transient improvement, she worsened again with breakthrough fever, hypotension, and worsening of thigh lesions with eschar formation. Wound debridement was done, and antibiotics were escalated to carbapenem and polymyxins. Tissue cultures (sent during wound debridement) grew carbapenem-resistant klebsiella pneumonia. With these, the fever and her wounds were better; but the fever still persisted and she described a persisting severe burning pain over both the thigh wounds which did not respond to several analgesics. A few days later, the fever worsened, and she had hypotension and disorientation. Blood and urine cultures were repeated. Repeat Serum beta D glucan levels were elevated. CSF examination was not possible in view of severe coagulopathy. The blood and wound cultures both grew C. neoformans (confirmed on MaldiTOFF). Antibiotics and anidulafungin were discontinued; liposomal amphotericin and flucytosine were started. Patient had significant improvement in sensorium, fever, and thigh pains within the next 72 h. Later, liposomal amphotericin was switched to conventional amphotericin because of financial constraints. This was followed by acute kidney injury and a flare of AIH. Amphotericin and flucytosine were withheld for a few days; a pulse of methylprednisolone was needed for AIH. Following resolution of acute kidney injury and AIH flare, conventional amphotericin B and flucytosine were restarted (and given for cumulative 3 weeks). This was followed by fluconazole consolidation. At hospital discharge, although there were raw areas over the thighs, these were healthy and she was otherwise well. A total of 3 months later, skin grafting was successfully performed. CONCLUSIONS: Cryptococcus can be a great masquerader, and can mimic a variety of conditions. A high index of suspicion is required to clinch the diagnosis.
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spelling pubmed-95161412022-09-29 P271 A masquerading case of Cryptococcus neoformans S, Divyashree Sontakke, Tushar Kulkarni, Satish Pandey, Ashok Thakur, Archana Debbarman, Panchami Yadav, Shalini Med Mycol Oral Presentations POSTER SESSION 2, SEPTEMBER 22, 2022, 12:30 PM - 1:30 PM:   INTRODUCTION: Cryptococcal infections are commonly seen in immunocompromised hosts, especially HIV-infected patients and patients on immunosuppressive therapy. Cryptococcus shows a strong tropism for the central nervous system however cutaneous tropism is not uncommon. Here we describe an HIV-negative immunocompromised patient who developed disseminated cryptococcosis with the predominant presentation being painful thigh lesions. CASE DETAILS: A 56-year-old lady presented with skin lesions and burning pain over both thighs for 1 month and a high-grade fever for 15 days. Her thigh lesions were initially treated elsewhere as tinea corporis. Her previous medical history was significant for poorly controlled diabetes, and chronic liver disease (secondary to autoimmune hepatitis or AIH). Her ongoing medications included prednisolone, anti-diabetics, and tenofovir. At presentation, the only significant physical findings were large irregular areas of central hypo-pigmentation with peripheral hyper-pigmentation and superficial small blisters over both thighs. These areas showed signs of inflammation. The empiric antimicrobial therapy included piperacillin-tazobactam and fluconazole (in view of prior urine culture growing Candida species). Over the next 48 h, fever continued, thigh pain worsened and the lesions on thighs blistered with violaceous discoloration. Her blood cultures sent at admission grew Candida kruzei, resistant to fluconazole, sensitive to voriconazole, amphotericin and echinocandins. Beta-D Glucan was also elevated. Fluconazole was discontinued, and anidulafungin was initiated. A repeat culture (prior to the start of anidulafungin) was still positive for C. krusei, but a subsequent blood culture (after the start of anidulafungin) was negative. Echocardiography did not show features of endocarditis. After a transient improvement, she worsened again with breakthrough fever, hypotension, and worsening of thigh lesions with eschar formation. Wound debridement was done, and antibiotics were escalated to carbapenem and polymyxins. Tissue cultures (sent during wound debridement) grew carbapenem-resistant klebsiella pneumonia. With these, the fever and her wounds were better; but the fever still persisted and she described a persisting severe burning pain over both the thigh wounds which did not respond to several analgesics. A few days later, the fever worsened, and she had hypotension and disorientation. Blood and urine cultures were repeated. Repeat Serum beta D glucan levels were elevated. CSF examination was not possible in view of severe coagulopathy. The blood and wound cultures both grew C. neoformans (confirmed on MaldiTOFF). Antibiotics and anidulafungin were discontinued; liposomal amphotericin and flucytosine were started. Patient had significant improvement in sensorium, fever, and thigh pains within the next 72 h. Later, liposomal amphotericin was switched to conventional amphotericin because of financial constraints. This was followed by acute kidney injury and a flare of AIH. Amphotericin and flucytosine were withheld for a few days; a pulse of methylprednisolone was needed for AIH. Following resolution of acute kidney injury and AIH flare, conventional amphotericin B and flucytosine were restarted (and given for cumulative 3 weeks). This was followed by fluconazole consolidation. At hospital discharge, although there were raw areas over the thighs, these were healthy and she was otherwise well. A total of 3 months later, skin grafting was successfully performed. CONCLUSIONS: Cryptococcus can be a great masquerader, and can mimic a variety of conditions. A high index of suspicion is required to clinch the diagnosis. Oxford University Press 2022-09-20 /pmc/articles/PMC9516141/ http://dx.doi.org/10.1093/mmy/myac072.P271 Text en © The Author(s) 2022. Published by Oxford University Press on behalf of The International Society for Human and Animal Mycology. https://creativecommons.org/licenses/by-nc-nd/4.0/This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact journals.permissions@oup.com
spellingShingle Oral Presentations
S, Divyashree
Sontakke, Tushar
Kulkarni, Satish
Pandey, Ashok
Thakur, Archana
Debbarman, Panchami
Yadav, Shalini
P271 A masquerading case of Cryptococcus neoformans
title P271 A masquerading case of Cryptococcus neoformans
title_full P271 A masquerading case of Cryptococcus neoformans
title_fullStr P271 A masquerading case of Cryptococcus neoformans
title_full_unstemmed P271 A masquerading case of Cryptococcus neoformans
title_short P271 A masquerading case of Cryptococcus neoformans
title_sort p271 a masquerading case of cryptococcus neoformans
topic Oral Presentations
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9516141/
http://dx.doi.org/10.1093/mmy/myac072.P271
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