P259 Rare presentations of Cryptococcosis: a case series
Authors: Perumalla Sowjanya , Singh Gagandeep , Xess Immaculata , Gaurav Sudesh , Sachdev Janya , Kabra S K 
Published: September 2022

Abstract

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

Objectives
Cryptococcus spp. is usually opportunistic pathogens affecting immunocompromised individuals causing meningitis primarily. Non-CNS presentations are a rare entity and we hereby present a series of 3 cases in the past 1 year (2021-2022).

Methods
Case records of the three patients were studied. Detailed history, demographic details, investigations, treatment were noted.

Results
Patient-1 was a 14-year-old girl who came with complaints of fever, pain, swelling, and restricted movements of the right wrist, elbow, and ankle joints with multiple subcutaneous swellings initially on the thigh followed by elbows, arms, and forearms. The swellings became hemorrhagic bullae bursting to form ulcers. She had a history of being treated 4 times for tuberculous lymphadenopathy. KOH-Calcofluor white mount of biopsy and pus aspirate samples showed circular yeast cells which were confirmed by cryptococcal antigen detection. All the samples had grown Cryptococcus neoformans on culture except blood, BAL, and CSF. She responded to Liposomal amphotericin-B drastically. Retesting of pus swabs from the ulcers after a week of antifungal therapy were negative for C. neoformans. Subcutaneous nodules and joint swellings decreased but she developed reactions to amphotericin B and was changed to fluconazole. She is on regular follow-up with no recurrence.
Patient-2 was a 22-year-old male, a known case of Hodgkin Lymphoma stage 4 who underwent Autologous stem cell transplantation (ASCT) and was on immunosuppressants. He presented with fever, dyspnea, and cough which got worsened along with multiple cervical, hilar and abdominal lymphadenopathy. KOH-Calcofluor white mount of biopsy samples demonstrated circular yeast cells which were confirmed by cryptococcal antigen detection test of biopsy and BAL samples. Cryptococcus neoformans was grown on culture from all the samples. He succumbed to ARDS and cardiorespiratory arrest before any treatment could be initiated.
Patient-3 was a 38-year-old female, known case of SLE with lupus nephritis, presented with intermittent fever, dyspnea, chest pain, decreased urinary output, and gradual swelling of the body starting from the face and progressing to the whole body. She further developed synpneumonic effusion, multiple erythematous tender papules over the right thigh, and cellulitis of the right lower limb. She was started on voriconazole in view of HRCT findings suggestive of fungal pneumonia. As galactomannan antigen test was negative, voriconazole was stopped. Pleural tap fluid flagged positive in Bactec and C. neoformans grown on subculture. Her condition worsened with septic shock and succumbed to the disease before any treatment could be initiated.

Conclusion
Subcutaneous, joint, and pulmonary involvement is rare, without a primary focus on the central nervous system. Culture and antigen detection can aid in early detection and hence early initiation of therapy.