A 42-year-old woman with history of heart failure status post orthotopic heart transplant and end stage renal disease presented to the hospital with decompensated heart failure that progressed to cardiogenic shock. She underwent a new orthotopic heart transplant and cadaveric donor kidney transplant. Three weeks later, she experienced right facial droop and right upper extremity weakness. Computed tomography showed a left frontal cortical lesion with vasogenic edema and a central hemorrhagic component. Given the concern for an angioinvasive mold infection, she was started on voriconazole and amphotericin B. Brain biopsy was performed and histopathology revealed septated hyphae with acute angle branching. Mycology culture isolated Curvularia sp. Unfortunately, her mental status deteriorated with subsequent development of multiorgan failure that led to death.
Cryptococcosis is a fungal infection that is typically associated with acquired immunodeficiency syndrome (AIDS). The advent of highly active antiretroviral therapy has decreased the frequency of this infection, but has led to the emergence of atypical cases of immune reconstitution inflammatory syndrome (IRIS). Here, we describe the case of a 40-year-old man who was diagnosed with HIV infection and cryptococcal meningitis. He was successfully treated with antifungals and then started antiretroviral therapy. The patient returned to the hospital 15 months later complaining of fever, pain, and neck swelling. A computed tomography (CT) scan revealed a conglomerate of necrotic lymph nodes in the supraclavicular region. He underwent biopsy and histology showed granulomatous inflammation with fungal elements, consistent with Cryptococcus. He tested positive for serum cryptococcal antigen. The patient was treated with liposomal amphotericin and flucytosine. After induction therapy, he was re-started on fluconazole. The final fungal cultures were negative. We attributed our patient’s clinical presentation to “paradoxical” IRIS, which was associated with his previously treated cryptococcosis. Near resolution of the supraclavicular mass was noted at the 3-month follow-up.
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