Pulmonary Cryptococcosis in the 2019 Novel Coronavirus, When the Coinfection Affects the Mortality

Abstract

Introduction: The 2019 Novel Coronavirus (COVID-19) is currently causing a pandemic all over the world. Many patients suffer from respiratory syndromes, including acute respiratory distress syndrome (ARDS). Coinfection with fungi is rare in these fragile patients but does increase the mortality risk in them. We present a case of COVID-19 who presented with shortness of breath and was found to have associated pulmonary cryptococcosis.Case presentation: A 78-year-old woman with hypertension and diabetes mellitus was transferred to our hospital with an upper GI bleed. Initially, she presented to another hospital after she was tested positive for COVID-19 and subsequently admitted due to shortness of breath. She was transferred to our critical care unit for a higher level of care after reporting melena and having a hemoglobin drop. She was in respiratory distress when admitted and was intubated. A culture from a deep tracheal aspirate grew Cryptococcus neoformans on admission. Cryptococcal antigen in her blood was negative. The patient was started on fluconazole. More history from her family indicated that she was immunocompetent with no chronic corticosteroid therapy or HIV. Lumbar puncture was done and showed an opening pressure of 34 cm H2O with 25 RBCs/mm3 and 5 WBCs/mm3, but it was performed after she received fluconazole for several days. The patient died with ARDS. Discussion: Cryptococcosis is a potentially life-threatening fungal infection usually caused by inhalation of C. neoformans or C. gatti spores. Severe cryptococcal disease occurs in immunocompromised patients but can also occur in immunocompetent adults. The association between fungal infection and COVID-19 has been reported with Aspergillus species. Yet, few reports are available about coinfection with Cryptococcus species and COVID-19. Considering that COVID-19 causes ARDS, coinfection with Cryptococcus species almost certainly increases inflammation in the lung and the risk for poor outcomes. Since corticosteroids are a necessary treatment in COVID-19 with respiratory symptoms and hypoxemia, initiating them in patients with cryptococcal infection should be closely monitored for the possibility of dissemination. Clinicians should obtain cultures for Cryptococcus species from blood and the central nervous system in COVID-19 patients with pulmonary cryptococcosis and balance the need for corticosteroids with the risk of cryptococcal dissemination.