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Fulminant myocardial cryptococcosis in an human immunodeficiency virus infected patient
Criptococosis miocárdica fulminante en un paciente con infección por el virus de la inmunodeficiencia humana
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=> array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Criptococosis miocárdica fulminante en un paciente con infección por el virus de la inmunodeficiencia humana" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => 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" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Silver staining observing the encapsulated yeasts where capsule is not stained with the ink.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Image granted by Dr. Tagmouti Ghita, Anatomical Pathology Service of the Hospital del Mar in Barcelona.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cryptococcosis is a systemic mycosis caused by <span class="elsevierStyleItalic">Cryptococcus neoformans</span>, 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).</p><p id="par0010" class="elsevierStylePara elsevierViewall">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 100<span class="elsevierStyleHsp" style=""></span>cells/ml the main determinant.</p><p id="par0015" class="elsevierStylePara elsevierViewall">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<span class="elsevierStyleHsp" style=""></span>°<span class="elsevierStyleSmallCaps">C</span> fever, with acute kidney failure (creatinine 7.9<span class="elsevierStyleHsp" style=""></span>mg/dl and urea 377<span class="elsevierStyleHsp" style=""></span>mg/dl) and lymphopenia 550/μl.</p><p id="par0020" class="elsevierStylePara elsevierViewall">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.</p><p id="par0025" class="elsevierStylePara elsevierViewall">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 <span class="elsevierStyleItalic">Pneumocystis jirovecii</span> 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 90<span class="elsevierStyleHsp" style=""></span>min maneuvers, without recovering rhythm at any time. The patient dies without us knowing the cause of the infection and cardiorespiratory arrest.</p><p id="par0030" class="elsevierStylePara elsevierViewall">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.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Reviewing the literature there are less than 20 published cases of cardiac involvement secondary to <span class="elsevierStyleItalic">C. neoformans</span>, reporting mainly endocarditis, myocarditis and pericarditis. Most of these reviews are prior to year 2000,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> probably due to the significant development of antiretroviral therapy in recent years.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">To diagnose cryptococcosis, <span class="elsevierStyleItalic">C. neoformans</span> 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<span class="elsevierStyleHsp" style=""></span>°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.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The clinical practice guidelines of the Infectious Diseases Society of America<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></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 (3–4<span class="elsevierStyleHsp" style=""></span>mg/kg/day) plus oral flucytosine (100<span class="elsevierStyleHsp" style=""></span>mg/kg/day); Consolidation phase with oral fluconazole (400<span class="elsevierStyleHsp" style=""></span>mg/day) for 8 weeks, and Maintenance phase with oral fluconazole (200<span class="elsevierStyleHsp" style=""></span>mg/day) at least 12 months, although in immunocompromised patients it is maintained until resolution of immunosuppression, or for life.</p><p id="par0050" class="elsevierStylePara elsevierViewall">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.</p><p id="par0055" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">5</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">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.</p>" ] ] "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" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Silver staining observing the encapsulated yeasts where capsule is not stained with the ink.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Image granted by Dr. Tagmouti Ghita, Anatomical Pathology Service of the Hospital del Mar in Barcelona.</p>" ] ] ] "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. 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