Disseminated Cryptococcosis with Adrenal and Lung Involvement in an Immunocompetent Patient

Abstract

A 65-year-old retired government officer presented to Department of Medicine of All India Institute of Medical sciences, New Delhi, India, with the complaints of high grade fever and significant weight loss for the last five months. He was a known case of Type 2 diabetes mellitus with good glycemic control on oral hypoglycemic agents (Tab Glimipiride 2 mg, Metformin 500 mg and Voglibose 0.3 mg daily). Patient denied any exposure to bird droppings or excessive dust from nearby civil construction or high risk behaviour. Besides, there was no past history of tuberculosis or contact with a patient with pulmonary tuberculosis.At the time of presentation, patient had fever and tachycardia. His body weight was 51 kg. Other general physical examination was unremarkable. Abdominal examination revealed mild hepatosplenomegaly with no free fluid. Other systems examination was non contributory. Hematological and biochemical investigation revealed an elevated ESR of 103 mm in first hour, deranged hepatic and renal function tests (serum creatinine 1.2 mg/dl, urea 53 mg/ dl, uric acid 8.9 mg/dl, AST 89 IU/L, ALT 49 IU/L, and Alkaline phosphatase 1022 IU/L). His fasting blood sugar was 153 mg/dl and HbA1c was 6.5%.Urine and blood cultures were sterile and peripheral smear for malaria was also negative. Chest radiograph was normal. Ultrasound abdomen revealed mild hepatosplenomegaly with bilateral adrenal masses. CECT of chest and abdomen showed fine miliary mottling

Disseminated Cryptococcosis with Adrenal Insufficiency and Meningitis in an Immunocompetent Individual

“…On comparing the findings in our patient with previously reported cases of adrenal insufficiency with cryptococcal infections, we noted several differences. The available reports have been summarized in Table 2 ( 9 - 13 ). We compared each case with respect to the systemic condition, complications, surgery, and environmental factors, especially contact with birds.…”

“…Meningitis or cryptococcal lung disease is the most common manifestation of cryptococcosis, as it rarely affects the adrenal glands; the infection is also more common in immunocompromised patients than in immunocompetent ones ( 4 - 8 ). Indeed, few reports exist of immunocompetent patients suffering from disseminated cryptococcosis ( 9 - 13 ).…”

“…Although adrenal gland involvement during cryptococcosis has been previously reported in immunocompetent patients ( 9 - 13 ), some cases have included diabetes mellitus, which increases a patient's susceptibility to infection.…”

Normalization of Bilateral Adrenal Gland Enlargement after Treatment for Cryptococcosis

“…In most of the reports, the enlargement was mentioned [5–8] at the diagnosis or did not change, even after the antifungal treatment was effective [9–14]. There is only one report which shows a decrease in adrenal gland enlargement after treatment with amphotericin B [15]; however, the images obtained after treatment clearly showed adrenal gland enlargement. This is the first report of a dynamic change in the size of adrenal glands infected with Cryptococcus from the exacerbation to recovery phase.…”

Unusual Presentations of Adrenal Masses

“…In most cases, cryptococcal antigen titers are elevated and used as a biomarker for disease resolution [21]. Intensive Amphotericin B therapy followed by oral fluconazole consolidation (usually 6-month course) is an effective multidrug treatment regimen Unusual Presentations of Adrenal Masses http://dx.doi.org/10.5772/intechopen.69393 [22,23]. In contrast to adrenal tuberculosis and histoplasmosis, adrenal insufficiency is often improved with resolution of this infection.…”