Fulminant myocardial cryptococcosis in an human immunodeficiency virus infected patient

Bosch-Compte, Raquel; Díaz, Yolanda; Masclans, Joan Ramon

doi:10.1016/j.medcle.2019.04.016

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Image granted by Dr. Tagmouti Ghita, Anatomical Pathology Service of the Hospital del Mar in Barcelona." ] ] ] "textoCompleto" => "Cryptococcosis is a systemic mycosis caused by Cryptococcus neoformans, acquired after the inhalation of its spores. It initially affects the lung, and eventually disseminates by hematogenous route, mainly to the central nervous system, causing meningoencephalitis. In addition, disseminated cryptococcosis can cause skin, visceral, bone and lung involvement (hypoxemia and even ARDS, which can be confused radiologically with pneumocystosis).The major role of cell-mediated immunity in defending the host against infection, and especially against dissemination, explains the high incidence of cryptococcosis in immunosuppressed patients, being CD4 lymphocyte count below 100cells/ml the main determinant.We present the rare case of a 42-year-old patient recently diagnosed with HIV, without having received antiretroviral therapy, who consulted the emergency department for head instability and 2 weeks of a 38°C fever, with acute kidney failure (creatinine 7.9mg/dl and urea 377mg/dl) and lymphopenia 550/μl.Oxygen saturation on room air was 94% with chest X-ray showing diffuse interstitial pattern and left parahilar mass, so the patient underwent empirical therapy with ceftriaxone and azithromycin after the diagnosis of probable pneumonia.In the following days, the patient presented acute hypoxemic respiratory failure, requiring admission to the intensive care unit and initiation of high-flow oxygen therapy. A chest CT scan showed pulmonary artery dilatation, enlargement of the right side of the heart and discrete pericardial effusion, mediastinal lymphadenopathy and diffuse ground-glass opacities with septal thickening suggestive of pulmonary edema possibly secondary to fluid overload without being able to rule out infectious origin. Due to the persistent respiratory distress, coverage was extended to cotrimoxazole due to the potential infection by Pneumocystis jirovecii and orotracheal intubation was performed. After this procedure, the patient presented with pulseless ventricular fibrillation, reason why advanced cardiopulmonary resuscitation maneuvers were initiated with 3 initial defibrillations. Subsequently, pulseless electrical activity alternates with asystole, requiring 13 adrenaline and 90min maneuvers, without recovering rhythm at any time. The patient dies without us knowing the cause of the infection and cardiorespiratory arrest.At necropsy, disseminated cryptococcosis becomes evident after special staining (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), with involvement of every organ assessed histologically (lung, heart, liver and mediastinal lymph nodes). The cause of death of the patient appears to be related to the extensive lung involvement and involvement of cardiac conduction system.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Reviewing the literature there are less than 20 published cases of cardiac involvement secondary to C. neoformans, reporting mainly endocarditis, myocarditis and pericarditis. Most of these reviews are prior to year 2000,<a class="elsevierStyleCrossRefs" href="#bib0030">1,2</a> probably due to the significant development of antiretroviral therapy in recent years.<a class="elsevierStyleCrossRef" href="#bib0040">3</a>To diagnose cryptococcosis, C. neoformans should be observed on direct examination of the organic specimen with India ink, and also it should be isolated it in the cultures in Sabouraud agar at 37°C. In addition, the cryptococcal antigen in the biological specimens confirms this diagnosis, and the titers are related to the severity of the disease and response to treatment.The clinical practice guidelines of the Infectious Diseases Society of America<a class="elsevierStyleCrossRef" href="#bib0045">4</a> recommend that disseminated cryptococcosis be treated as a meningoencephalitis, being divided into 3 phases: Induction phase that usually lasts 14 days (although it can last up to 6 weeks in case of neurological complications or poor response to therapy). This phase consists of intravenous liposomal amphotericin b (3–4mg/kg/day) plus oral flucytosine (100mg/kg/day); Consolidation phase with oral fluconazole (400mg/day) for 8 weeks, and Maintenance phase with oral fluconazole (200mg/day) at least 12 months, although in immunocompromised patients it is maintained until resolution of immunosuppression, or for life.The diagnosis is important since, without proper therapy, it leads to high mortality rate, as it happened with the patient in this case. In recent years, the prognosis of cryptococcosis has been improved with the better completion and optimization of antiretroviral therapies.The interest of this review lies in the rare cases of cardiac involvement reported in the literature, usually immunosuppressed patients with multi-organ involvement by C. neoformans where heart disease is detected as a necropsy finding, as in this case.<a class="elsevierStyleCrossRef" href="#bib0050">5</a>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Bosch-Compte R, Díaz Y, Masclans JR. Criptococosis miocárdica en un paciente con infección por el virus de inmunodeficiencia humana. Revisión a raíz de un caso clínico fulminante. Med Clin (Barc). 2019;152:e71–e72." ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 931 "Ancho" => 900 "Tamanyo" => 107990 ] ] "descripcion" => array:1 [ "en" => "Silver staining observing the encapsulated yeasts where capsule is not stained with the ink. Image granted by Dr. Tagmouti Ghita, Anatomical Pathology Service of the Hospital del Mar in Barcelona." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cryptococcal endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Alhaji" 1 => "R.T. Sadikot" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/SMJ.0b013e3182142ba0" "Revista" => array:6 [ "tituloSerie" => "South Med J" "fecha" => "2011" "volumen" => "104" "paginaInicial" => "363" "paginaFinal" => "364" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21606721" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cryptococcal myocarditis in acquired immune deficiency syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "W. Lewis" 1 => "J. Lipsick" 2 => "C. Cammarosano" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Cardiol" "fecha" => "1985" "volumen" => "55" "paginaInicial" => "1240" "itemHostRev" => array:3 [ "pii" => "S0210569115000741" "estado" => "S300" "issn" => "02105691" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Overview on the incidence and the characteristics of HIV-related opportunistic infections and neoplasms of the heart: impact of highly active antiretroviral therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R. Bruno" 1 => "P. Sacchi" 2 => "G. Filice" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "AIDS" "fecha" => "2003" "volumen" => "17" "numero" => "Suppl. 1" "paginaInicial" => "S83" "paginaFinal" => "S87" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12870535" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of America" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.R. Perfect" 1 => "W.E. Dismukes" 2 => "F. Dromer" 3 => "D.L. Goldman" 4 => "J.R. Graybill" 5 => "R.J. Hamill" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/649858" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2010" "volumen" => "50" "paginaInicial" => "291" "paginaFinal" => "322" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20047480" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fungal myocarditis in acquired immunodeficiency syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Hofman" 1 => "M. Gari-Toussaint" 2 => "E. Bernard" 3 => "J.F. Michiels" 4 => "P. Gibelin" 5 => "Y. Le Fichoux" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Mal Coeur Vaiss" "fecha" => "1992" "volumen" => "85" "paginaInicial" => "203" "paginaFinal" => "208" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1562224" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015200000012/v1_201906160657/S2387020619302001/v1_201906160657/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015200000012/v1_201906160657/S2387020619302001/v1_201906160657/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020619302001?idApp=UINPBA00004N"]

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Vol. 152. Issue 12.

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