Fatal Disseminated Cryptococcosis Resembling Miliary Tuberculosis in a Patient with HIV Infection

Abstract

A 51-year-old man was transferred to our hospital due to acute respiratory failure that had progressed over four days. A chest X-ray and thoracic computed tomography scan showed multiple faint micronodules randomly distributed throughout both lungs with ground glass opacity, suggesting miliary tuberculosis or Pneumocystis jirovecii pneumonia with acute respiratory distress syndrome. Six hours after admission, the patient died of septic shock. Later, the cryptococcal antigen titer was found to be markedly elevated (1/65,536), with a positive result for anti-human immunodeficiency virus and a low CD4 cell count (12/μL). The present case is reminder that disseminated cryptococcosis with HIV infection can be misdiagnosed as miliary tuberculosis based on radiological findings.

Polyvalent vaccines: High-maintenance heroes

“…Forty HPV types are capable of infecting mucosal epithelium and are grouped into non-oncogenic and oncogenic serotypes according to their epidemiologic association with cervical cancer [ 2 ]. In the US, there are three HPV vaccines licensed: Gardasil (2006), a quadrivalent vaccine against HPV types 6, 11, 16, and 18 [ 19 ]; Cervarix (2009, discontinued in 2016), a bivalent vaccine against HPV types 16 and 18 [ 20 ]; and Gardasil 9 (2014), a 9-valent vaccine against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 [ 21 ]. The vaccines consist of recombinant L1 proteins that self-assemble into highly immunogenic viruslike particles (VLPs).…”

“…The vaccines consist of recombinant L1 proteins that self-assemble into highly immunogenic viruslike particles (VLPs). The L1 protein VLPs are either produced by separate fermentation of recombinant yeast ( Saccharomyces cerevisiae ) or by expression in an insect producer cell line infected with baculovirus containing the L1 gene [ 20 , 21 ]. Cervarix contains a proprietary adjuvant, AS04, while Gardasil is adjuvanted with aluminum hydroxyphosphate sulfate [ 20 , 21 ].…”

“…The L1 protein VLPs are either produced by separate fermentation of recombinant yeast ( Saccharomyces cerevisiae ) or by expression in an insect producer cell line infected with baculovirus containing the L1 gene [ 20 , 21 ]. Cervarix contains a proprietary adjuvant, AS04, while Gardasil is adjuvanted with aluminum hydroxyphosphate sulfate [ 20 , 21 ]. Both Gardasil and Cervarix confer immunity against HPVs 16 and 18, which are responsible for 70% of all cervical cancers, while Gardasil also immunizes against two HPV types that cause about 90% of genital warts [ 2 ].…”

Pulmonary and Extrapulmonary Manifestations of Fungal Infections Misdiagnosed as Tuberculosis: The Need for Prompt Diagnosis and Management

“…The clinical features of pulmonary cryptococcosis may mimic pulmonary TB resulting in misdiagnosis of cases especially in areas highly endemic for TB including Asia and Africa [ 39 , 42 , 43 ]. In addition, abnormal radiologic findings in cryptococcal disease including nodules, pulmonary infiltrates, pleural effusions, hilar lymphadenopathy, lung cavitation and osteolytic lesions are also found in TB [ 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ]. Furthermore, in the absence of India ink, the large encapsulated yeast may be mistaken for lymphocytes in CSF microscopy.…”

“…Cryptococcal infections may also coexist with TB in severely immunocompromised individuals [ 91 ]. Delayed diagnosis often results in death [ 40 , 41 , 43 , 46 , 47 ]. Of the 11 patients with cryptococcosis misdiagnosed as TB, 9 were negative for AFB/Gene Xpert, results of AFB/Gene Xpert were not stated in two cases, three were HIV positive, five died due to delayed diagnosis and commencement of antifungal therapy and six recovered ( Table 1 and Table 5 ).…”