Primary Larynx Cryptococcus neoformans Infection: A Distinctive Clinical Entity

Endobronchial cryptococcosis with bronchial stenosis in a patient with severe asthma treated with inhaled corticosteroids: A case report

Cryptococcosis typically manifests as pulmonary lesions, with endobronchial lesions occurring rarely. Inhaled corticosteroids (ICS) may be a risk factor for cryptococcosis of the larynx but not of the bronchi. Here, we report a case involving a 73-year-old Japanese man who developed endobronchial cryptococcosis during ICS treatment for asthma. Chest computed tomography showed right mainstem bronchial stenosis and asthma control worsening when he received adequate asthma treatments. Bronchoscopy revealed multiple elevated lesions with white slough from the trachea to the right mainstem bronchus and the right mainstem bronchus lumen entrance narrowing. Bronchial lavage culture revealed Cryptococcus neoformans. Combination treatment with the antifungal agent, mepolizumab, and bronchodilation surgery successfully controlled cryptococcosis and asthma. Attention should be paid to central airway lesions during ICS treatment for uncontrolled asthma.

Cryptococcal laryngitis in an immunocompetent asthmatic patient using inhaled corticosteroids

We present a case of laryngeal cryptococcosis caused by cryptococcosis neoformans var. grubii affecting a patient using excessive inhaled corticosteroids. The patient experienced symptoms for several months prior to specialist review and the visualization of a mass lesion by nasopharyngoscopy. Fortunately a biopsy was performed and through histopathology & microbiological assessment a diagnosis of cryptococcal laryngitis was made. Treatment with 6 months of fluconazole resulted in clinical cure and resolution of symptoms. It is important to raise awareness of the risk of non-Candida fungal infections in patients on high dose corticosteroids, especially in the post covid era were steroids are more commonly prescribed.

Cryptococcal Laryngitis: Three Cases Managed With Potassium-Titanyl-Phosphate Laser and Literature Review

OBJECTIVES

To present three case reports of cryptococcal laryngitis managed with potassium-titanyl-phosphate (KTP) laser, where only one case managed with KTP laser has previously been published to date to our knowledge. Further, to systematically review the medical literature and describe the epidemiology, clinical assessment, treatment, and prognosis of laryngeal cryptococcosis.

METHODS

The PubMed, Embase, and OVID MEDLINE databases were searched using the terms "cryptococcal laryngitis" or "cryptococcus" and "larynx or laryngeal."

RESULTS

Thirty-eight cases were identified. The median age was 65 years with a 1 male:1.2 female ratio. Thirty-six cases (95%) presented with hoarseness. Twenty-one cases (55%) were systemically immunosuppressed and 19 (50%) were taking an inhaled corticosteroid. This paper lists the five clinical features (i. white exudate or lesion; ii. exophytic, verrucous or tumor-like mass; iii. diffuse erythema; iv. mucosal irregularity; v. thickened vocal fold) and four pathologic features or tests (i. Grocott Gomori Methenamine stain; ii. Mucicarmine stain; iii. fungal or yeast organisms; iv. fungal culture) that encompass 97% of cases of cryptococcal laryngitis reported in the medical literature. In 34 cases (89%), antifungal therapy was given. Four cases (11%) had excisional biopsy and 11 (29%) received combined surgery and medical therapy. There was uncomplicated resolution in 24 cases (63%).

CONCLUSION

Cryptococcal laryngitis is a rare cause of hoarseness that may be mistaken for malignancy or may be a manifestation of disseminated cryptococcal infection or underlying immunosuppression. Clinicians should be aware of the diagnostic features of cryptococcal laryngitis to facilitate diagnosis and treatment to prevent complicated disease and overly aggressive treatment.

Primary laryngeal cryptococcosis mimicking laryngeal malignancy: a case report

Primary laryngeal cryptococcosis is an extremely rare infection and presents with non-specific symptoms such as hoarseness or sore throat, resulting in delayed diagnosis. Here, we report the patient of a 56-year-old female patient with primary laryngeal cryptococcosis, who was being treated with oral and inhaled steroids for rheumatoid arthritis and bronchial asthma. The patient suffered from prolonged hoarseness and sore throat, and endoscopic biopsy was performed several times under local anesthesia, demonstrating only inflammatory cell infiltration. Considering the possibility of laryngeal malignancy, a third biopsy was performed by endoscopic laryngomicrosurgery under general anesthesia. Intraoperative frozen section revealed non-neoplastic laryngeal mucosa with erosion and severe inflammatory cell infiltration. However, we could not confirm the definite diagnosis of the lesion in the intraoperative consultation. Postoperative histopathological examination revealed a small number of yeast-type fungi and a definitive diagnosis was established by special stains including Alcian blue stain. Finally, the patient was diagnosed as primary laryngeal cryptococcosis. Daily oral administration of fluconazole (400 mg/day) was performed for 6 months according to the treatment protocol for pulmonary cryptococcosis. The symptoms gradually improved, and endoscopy revealed no recurrence 6 months post-treatment. Clinicians should consider the possibility of laryngeal cryptococcosis when severe inflammation is found in the larynx and discuss the disease history and pathological results with pathologists more closely.

Cryptococcosis in the Vocal Cords, Trachea, and Bronchi

Laryngeal and endobronchial cryptococcosis are rare conditions, and to our knowledge, there have been only 23 cases of laryngeal cryptococcosis, and 18 cases of endobronchial cryptococcosis previously reported in the English literature. We herein report an extremely rare case of cryptococcosis with simultaneous laryngeal and endobronchial involvement. This case highlights the importance of paying close attention to possible occurrence of cryptococcosis of the airway tract in patients with asthma treated with high-dose inhaled corticosteroids.

Cryptococcus Infection in Captive Callitrichids in the United Kingdom

Cryptococcosis is widely reported in North America and Australia but considered rare in the UK. Disease is mainly caused by Cryptococcus neoformans and Cryptococcus gattii and affects animals and humans. Cases of cryptococcosis have been described in non-human primates, including a few in the Callitrichidae family. Six captive callitrichids from five zoological facilities in the UK were diagnosed with cryptococcosis on post-mortem examination over a 13-year period. Histological examination revealed intralesional yeast bodies consistent with Cryptococcus spp in lung, brain, lymph nodes, larynx, salivary gland and ears. C. neoformans was confirmed in two cases by culture and by culture and polymerase chain reaction (28S rRNA gene), respectively. This case series is the first report of Cryptococcus spp in captive callitrichids in the UK and reinforces the need to include this fungal disease in the differential diagnosis of sick callitrichids in zoo settings.

Laryngeal Cryptococcosis: An Evolving Rare Clinical Entity

Objectives:

Describe the demographics and clinical manifestations of laryngeal cryptococcosis. Develop a simple approach to the diagnostic workup and treatment of localized laryngeal cryptococcal infection.

Methods:

A new case of laryngeal cryptococcosis encountered at our institution is presented and placed in context of the literature surrounding prior reported cases. PubMed, Google Scholar, SCOPUS, and Web of Science were queried from inception to August 2018 with the terms Larynx or Laryngeal and Cryptococcosis or Cryptococcus by two independent reviewers for English-language cases of cryptococcal infection of the larynx.

Results:

Twenty-nine unique cases of laryngeal cryptococcosis were identified. Median age at presentation was 65 years old. All patients presented with persistent or progressive hoarseness. Lesions were predominantly on the true vocal cords (79%), 38% associated with an adherent white exudate or leukoplakia. A minority (28%) was immunocompromised, and of the remaining immunocompetent hosts, 67% were found to be using nebulized or inhaled corticosteroids (ICS) prior to infection. Diagnosis should be suspected in patients with chronic laryngitis or mass lesions with the aforementioned risk factors. Diagnosis was made by histopathology with cryptococcal yeasts identified on methenamine silver (55%) and/or mucicarmine stains (48%). Serum cryptococcal antigen testing was unreliable (sensitivity = 39%). The mainstay of effective treatment was prolonged oral Fluconazole therapy, with two cases of laser therapy ablation of residual lesions. Improvement in voice and vocal lesions varied from weeks to months.

Conclusions:

Laryngeal cryptococcosis is a rare cause of persistent hoarseness, which appears to be clinically evolving and more frequently affecting immunocompetent hosts chronically using nebulized or inhaled corticosteroids. Laryngeal cryptococcal infection is readily treatable with prolonged oral antifungals once biopsy and histopathological stains confirm the diagnosis.

Laryngeal Cryptococcoma Resulting in Airway Compromise in an Immunocompetent Patient: A Case Report

Cryptococcus neoformans is a yeast than can result in isolated or disseminated infections. This case report describes an immunocompetent patient presenting with airway obstruction secondary to laryngeal crypotococcoma, mimicking a laryngeal malignancy, and describes associated management. A 68-year-old immunocompetent female with a new positron emission tomography-avid laryngeal lesion was intubated after acute respiratory decompensation. Airway evaluation revealed diffuse mucosal changes throughout the endolarynx with significant loss of normal native tissue architecture. Operative biopsy confirmed infection of C neoformans. The patient was treated with extended-course fluconazole. This case reinforces characteristic physical and histologic findings described for laryngeal cryptococcal infection. Laryngoscope, 129:926-929, 2019.

Laryngeal Cryptococcosis Associated With Inhaled Corticosteroid Use: Case Reports and Literature Review

Laryngeal cryptococcosis is a rare clinical entity. There have been a limited number of case reports in the literature with no consensus regarding optimal management. This review contributes two additional case reports of immunocompetent patients with cryptococcal infection of the larynx in whom exposure to high doses of inhaled corticosteroids is proposed as a significant risk factor. Twenty cases were identified from review of the literature. All patients presented with hoarseness and a spectrum of microlaryngoscopic features, often mimicking laryngeal malignancy. The majority of cases were treated with systemic antifungal therapy, three cases had surgical excision alone, and another three had a combination of medical and surgical management. Risk factor modification, in the form of a reduction in inhaled corticosteroid was employed in the two new cases, and in some previously published cases. Risk factor modification, such as reduction of inhaled corticosteroid dose, in addition to oral antifungal agents can be effective in managing cryptococcal laryngitis.