COVID 19 Pneumonia Leading to a Delayed Diagnosis of Cryptococcal Pneumonia: Collateral Damage in a Pandemic

Abstract

Introduction The COVID-19 pandemic has overwhelmed the healthcare system forcing a change in hospital practices. Currently, hospital admissions are reserved for higher acuity patients. We describe a patient with delayed diagnosis of cryptococcal pneumonia with COVID-19 co-infection. Case Description A 55-year-old Peruvian male with a history of latent tuberculosis presented with worsening cough and dyspnea. Two months prior to this admission, the patient's primary care physician treated the patient for community-acquired pneumonia with doxycycline and azithromycin. CT chest showed a lingular consolidation, mediastinal lymphadenopathy and bilateral pulmonary nodules. His COVID-19 PCR was positive. Due to the absence of hypoxia, dexamethasone and remdesivir were not prescribed. He was treated with broad-spectrum antibiotics. An outpatient bronchoscopy was planned to be scheduled once his COVID-19 PCR was negative. Three weeks after initial presentation and prior to the bronchoscopy, the patient returned with worsening dyspnea, nausea and vomiting. His COVID-19 PCR was negative. He underwent both bronchoscopy with lavage and CT guided lung biopsy. Cultures from the BAL and biopsy found fungal elements resembling cryptococcal forms. Lumbar puncture noted elevated intracranial pressure (ICP) and the CSF identified cryptococcal species. The serum cryptococcal antigen was elevated. His HIV test was negative, absolute CD4 count was 339 cells/mcL. His cryptococcal meningitis and elevated ICP's resulted in generalized tonic-clonic seizures. His altered mental status worsened and he was intubated. Liposomal amphotericin and flucytosine were prescribed. Serial lumbar punctures and CSF drainage controlled his increased intracranial pressures. Cultures from multiple sites grew Cryptococcus gatti. His condition slowly improved and he was subsequently extubated. Discussion Central nervous system cryptococcosis in non-HIV infected patients generally occurs in patients with solid organ transplant, rheumatic disorders or CD4 lymphopenia. It is rarely seen in immunocompetent hosts, however is known to be a harbinger of subclinical immunodeficiency. The outcomes are dependent on high index of suspicion, early diagnosis and aggressive treatment. C. gatti is inhaled as aerosolized particles, causing a distinct and larger inflammatory response than C. neoformans Depending upon the host's immune status, C. gatti may cause asymptomatic pulmonary infections up to potentially life-threatening CNS infections. This pandemic has interrupted normal patterns of health care, often leading to missed or delayed diagnosis. Our case underscores the importance of maintaining a high level of suspicion for uncommon diseases. Clinicians need to develop a varied differential diagnosis in order to perform appropriate testing and initiate treatment for life threatening non- COVID-19 conditions.