Unilateral leg pain caused by cryptococcal myositis: An unusual presentation of disseminated cryptococcosis in a kidney transplant recipient

Abstract

Cryptococcal disease is a rare but often serious infection in solid organ transplant recipients, commonly presenting as meningitis and pneumonia but can rarely cause myositis. We report the case of a 43‐year‐old female kidney transplant recipient with two previous graft failures requiring re‐transplantations who presented with a 1‐month duration of worsening unilateral leg pain, swelling, and shortness of breath. Blood cultures isolated Cryptococcus neoformans. A calf biopsy was performed and histopathology revealed myonecrosis with yeast forms consistent with Cryptococcus spp. Liposomal amphotericin B (LamB) was administered. Her course was complicated by hypoxemic respiratory failure with development of ground glass opacities on chest imaging. Work‐up revealed bacterial and C neoformans pneumonia and probable Pneumocystis jirovecii pneumonia (PJP) She received trimethoprim‐sulfamethoxazole and LamB and was discharged on fluconazole. Shortly thereafter she was re‐admitted with confusion, septic shock, and multi‐organ failure. Work‐up revealed PJP with subsequent development of cryptococcal meningitis. Despite aggressive management, she expired. Disseminated cryptococcal infection may manifest as myositis. Presence of cryptococcal infection is a marker of severe net state of immunosuppression (IS), hence, presence of other opportunistic infections is likely. Early recognition of cryptococcal infection, institution of targeted therapy, and IS reduction are important to improve overall survival.

Cryptococcal myositis and monoarthritis in a failed renal allograft recipient

“…4 Cryptococcal myositis is a rare clinical scenario characterized by intermittent fever, limb swelling, and leucocytosis with elevated erythrocyte sedimentation rate. 6 Normal CPK levels, sterile blood cultures, and negative serum cryptococcal antigen are characteristic laboratory features present in nearly 70% of cases of cryptococcal myositis, 7 which is similar to our case. MRI of the involved muscle compartment will reveal nonspecific inter and intramuscular edema, increased muscle size and increased signal intensity in T2 weighted images.…”

“…To our knowledge, the combined occurrence of cryptococcal myositis with monoarthritis has not been reported in renal transplant recipients, and this entity is restricted to a handful of case reports in the medical literature in association with conditions like B cell lymphoma 5 and diabetes mellitus 4 . Cryptococcal myositis is a rare clinical scenario characterized by intermittent fever, limb swelling, and leucocytosis with elevated erythrocyte sedimentation rate 6 . Normal CPK levels, sterile blood cultures, and negative serum cryptococcal antigen are characteristic laboratory features present in nearly 70% of cases of cryptococcal myositis, 7 which is similar to our case.…”