Images in ID — What's the Diagnosis? Persistent Hoarseness in a Former Smoker

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.

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.