Cryptococcal Pneumonia in a Patient with recent COVID19 infection

Background

COVID-19 has been linked to numerous opportunistic infections, including various fungal diseases such as Aspergillosis, Mucormycosis, Histoplasmosis, Blastomycosis, and Cryptococcus. Here we present a case of pulmonary cryptococcus infection in a patient who developed severe worsening cryptococcal infection with recent COVID-19 infection.

Case Presentation

A 77-year-old Caucasian male presented to the emergency department for shortness of breath, progressive generalized weakness, and hypotension. His past medical history is significant for diabetes mellitus II, polymyalgia rheumatica requiring prednisone use (5 mg daily), and hypertension. He was diagnosed with COVID-19 infection two weeks before these current symptoms, required admission to an outlying facility, and was treated for pneumonia. After discharge, he completed his antibiotic course, but one week later, he noticed worsening symptoms. He was seen a day prior at the clinic where it was revealed that the patient had an elevated white blood count, acute kidney injury, and a chest radiograph showing bilateral pulmonary infiltrates. Chest CT with contrast revealed extensive, severe bilateral airspace disease with necrotizing pneumonia. He was admitted to the hospital and started on antibiotics including anti-fungal coverage. Pulmonology was consulted, a bronchoscopy was performed, and serology testing came positive for cryptococcal antigen. He was started on fluconazole with improvement in symptoms. He was discharged home with pulmonology and infectious disease follow-up.

Discussion

Severe COVID-19 infection can cause ARDS and intense inflammation creating the need for corticosteroids. High-dose corticosteroids along with comorbidities like Diabetes Mellitus make the patients susceptible to opportunistic infections. Our patient has a history of Polymyalgia Rheumatica, for which he has been taking low-dose corticosteroids, as well as Diabetes Mellitus. In addition to this, he has been administered high-dose corticosteroids for treatment of recent COVID-19 infection. These factors made him susceptible to Cryptococcal infection. The literature review showed many cases of aspergillosis and COVID-19 infection, but pulmonary cryptococcal was less documented. In COVID-19 patients with rapidly worsening respiratory failure and not responding to traditional treatment suspicion of superimposed fungal infection should be considered. Diagnosis can be made with the detection of cryptococcal antigen as broncho-alveolar lavage cultures are not very sensitive or specific. The first-line treatment for pulmonary cryptococcus is fluconazole or amphotericin B/flucytosine in patients with CNS involvement.

Pulmonary cryptococcal infection is difficult to diagnose as it can mimic multiple conditions including lung cancer, tuberculosis, and bacterial pneumonia with consolidation. Early recognition and diagnosis of pulmonary cryptococcal infection can prevent morbidity and mortality.