Thanks to Dr. Barton for being our faculty expert today to discuss a case of disseminated Cryptococcus! The patient we discussed today did not have the usual risk factors for this infection, which we typically think about in patients who have compromised cellular immunity. Particular patient populations at risk include patients with HIV, hematopoietic stem cell transplant recipients, and solid organ transplant recipients.
Cryptococcus is a budding yeast with a capsule, seen here on silver stain:
The most common sites of Cryptococcus infection are the lungs and the CNS. It can also cause skin infection, particularly in HIV patients, which can resemble molluscum in appearance. If Cryptococcus is cultured from any other organ, it should be treated as disseminated infection.
Although disseminated Cryptococcus and cryptococcal meningitis should be treated with the same medications, it is still important to perform an LP in someone with cryptococcemia to check opening pressure — it is frequently elevated in patients with CNS involvement of disseminated Cryptococcus, which can have serious consequences and may require treatment with CSF removal.
Below are guidelines for treatment of disseminated Cryptococcus in non-HIV non-transplant hosts, from the Infectious Disease Society of America. Basically, there are three stages of treatment: induction, consolidation, and maintenance. The induction phase should involve a combination of amphotericin and flucytosine, followed by consolidation with high dose fluconazole and maintenance with lower dose fluconazole.
See below for a reference of a case report similar to our own patient!
Okamoto K, Proia LA, Demarais PL. Disseminated Cryptococcal Disease in a Patient with Chronic Lymphocytic Leukemia on Ibrutinib. Case Rep Infect Dis. 2016;2016:4642831. Epub 2016 Sep 14.