Multiple osseous involvements in a case of disseminated cryptococcosis

Isolated cryptococcosis of a lumbar vertebra in an immunocompetent patient: A case report and literature review

Background

Cryptococcus, a kind of fungus, can be found in soil, decayed wood, and avian excreta. Immunocompromised patients are prone to infection caused by Cryptococcus, and the lungs and central nervous system are the main target organs. Cryptococcosis rarely occurs in the lumbar vertebra or in immunocompetent patients.

Case presentation

A 40-year-old adult male with isolated lumbar vertebra cryptococcosis at the L4 vertebra underwent successful lesion removal surgery performed via the posterior approach and postoperative administration of an antifungal agent. At the 12-month follow-up, the patient's pain was relieved, and his motor function had improved. Isolated Cryptococcus vertebrae infection is a rare infectious disease.

Conclusions

A needle biopsy can confirm the diagnosis of Cryptococcus infection. When patients present with unbearable symptoms of nerve compression, posterior depuration combined with postoperative antifungal agents is a good option.

Disseminated cryptococcal infection in an immunocompetent patient treated with short course induction therapy

A 49- year old immunocompetent male presented with a right flank abscess and was found to have disseminated cryptococcal disease. Treatment was initiated with a one-week intravenous regime of amphotericin B and flucytosine based on recent trial data that this is as effective, and less toxic, than the standard two weeks. After completion of intravenous treatment he was discharged with oral anti-fungals and is making a good recovery with ongoing follow up.

Disseminated cryptococcosis with recurrent multiple abscesses in an immunocompetent patient: a case report and literature review

Background

Cryptococcus neoformans is frequently present as an opportunistic pathogen mainly affecting immunocompromised populations. Disseminated C. neoformans infection in immunocompetent population is rare and usually involves lung and central nerve system. Cryptococcus from biologic samples can easily grow on routine fungal and bacterial culture media. Besides, cryptococcal latex agglutination test has been established as a reliable diagnostic tool with overall sensitivities of 93–100%.

Case presentation

We report a rare disseminated cryptococcosis case which presented with chronic recurrent multiple abscess in an immunocompetent male involving skin, lung, spine and iliac fossa without evidence of central nerve system involving. The results of serum cryptococcal latex agglutination tests and standard microbial cultures were negative. The patient underwent empirical anti-bacterial and anti-tuberculosis therapy which turned out to be effectless. Finally, bedside inoculation of the pus was carried out and revealed Cryptococcus neoformans, which was confirmed by polymerase chain reaction. After the administration of anti-fungal drugs including liposomal amphotericin B, the patient recovered from fever and paraplegia.

Conclusions

This case reveals an uncommon pattern of disseminated C. neoformans infection in immunocompetent population presented with chronic multiple abscess and without central nerve system involving. Negative routine microbial cultures may not necessarily rule out cryptococcosis, especially in early stage. Besides, cryptococcal latex agglutination test does have a chance of false negative, which might be related with “capsule-deficiency”. Moreover, this phenomenon could be related with low-grade virulence and relative long illness duration.

Skeletal cryptococcosis from 1977 to 2013

Skeletal cryptococcosis, an aspect of disseminated cryptococcal disease or isolated skeletal cryptococcal infection, is a rare but treatable disease. However, limited information is available regarding its clinical features, treatment, and prognosis. This systematic review examined all cases published between April 1977 and May 2013 with regard to the factors associated with this disease, including patient sex, age, and epidemiological history; affected sites; clinical symptoms; underlying diseases; laboratory tests; radiological manifestations; and delays in diagnosis, treatment, follow-up assessments, and outcomes. We found that immune abnormality is a risk factor but does not predict mortality; these observations are due to recent Cryptococcus neoformans var gattii (CNVG) outbreaks (Chaturvedi and Chaturvedi, 2011). Dissemination was irrespective of immune status and required combination therapy, and dissemination carried a worse prognosis. Therefore, a database of skeletal cryptococcosis cases should be created.

A rare case of cryptococcal infection of talus with pathological fracture that healed with medical management

Skeletal involvement occurs in 5% to 10% of reported cases of disseminated cryptococcal infection. We are reporting a very rare presentation of cryptococcal infection of the talus with pathological fracture, which healed with medical management. Our patient had pain and swelling around the ankle associated with fever. Radiologically, he had a lytic lesion of the talus with fracture of the talar neck. Biopsy and cultures revealed cryptococcal infection. He was treated with surgical debridement combined with antifungal therapy, and the fracture healed well by 5 months. At the end of the 1-year follow-up, he had painless ankle movement and there was no evidence of recurrence. He was able to walk without support or limp, and he could wear normal footwear.