Disseminated Cryptococcosis in an Immunocompromised Patient with Altered Mental Status and a Lung Nodule

Disseminated cryptococcosis is an opportunistic infection that commonly affects the central nervous and respiratory systems and is often fatal in immunocompromised host patients. Diagnosing disseminated cryptococcosis is challenging at times due to the nonspecific presentation, resulting in delayed treatment and increased mortality.

A 48-year-old man presented with altered mental status and shortness of breath requiring intubation. Medical history was significant for rheumatoid arthritis, diabetes mellitus, chronic kidney disease, sarcoidosis, and polymyalgia rheumatica. Home medications included prednisone, methotrexate, and tocilizumab. Computed tomography chest revealed multifocal pneumonia with a cavitary nodule with halo sign. One week after extubation, the patient remained confused. Lumbar puncture (LP) was positive for Cryptococcus neoformans within 5 days. Bronchoalveolar lavage (BAL) yielded similar results on fungal culture one month later.

An immunocompromised host patient who presents with altered mental status with concomitant lung nodules should have disseminated cryptococcosis as a differential diagnosis. CT chest commonly demonstrate peripheral lung nodules with cavitation, air bronchograms, halo sign, and/or enlarged mediastinal lymphadenopathy, as found in our patient. If the clinical suspicion for disseminated cryptococcosis is high, an LP should be performed, as BAL results may often be delayed since Cryptococcus grows slowly from the lungs. Empiric antifungals should be started immediately, given increased mortality if treatment is delayed.