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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 25  |  Issue : 1  |  Page : 45-47

Cryptococcus laurentii: An unusual cause for atypical pneumonia in hematological malignancy


Department of Microbiology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India

Date of Submission20-Dec-2018
Date of Acceptance09-Jan-2020
Date of Web Publication14-Apr-2020

Correspondence Address:
Dr. Swati Jain
142, Doctors Enclave, Campus-3, Institute of Medical Sciences and SUM Hospital, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmgims.jmgims_65_18

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  Abstract 


Cryptococcus laurentii, one of the nonneoformans Cryptococcus is a known biopesticide to control fruit rot, previously considered to be nonpathogenic to humans, is now have been reported as a cause of opportunistic infections. Here, we present a case of pulmonary cryptococcosis due to C. laurentii in a patient with chronic lymphocytic leukemia and prolymphocytic leukemia. Sputum microscopy showed Gram-positive spherical capsulated budding yeast cells, culture of which revealed it as C. laurentii. The patient was promptly put on fluconazole, but he died on the subsequent day after initiation of therapy. A high index of suspicion and improvement of techniques of culture and identification is essential for early diagnosis and treatment of unusual fungal infections.

Keywords: Cryptococcus laurentii, chronic lymphocytic leukemia, prolymphocytic leukemia


How to cite this article:
Kabi S, Jain S, Swain B, Sharma N. Cryptococcus laurentii: An unusual cause for atypical pneumonia in hematological malignancy. J Mahatma Gandhi Inst Med Sci 2020;25:45-7

How to cite this URL:
Kabi S, Jain S, Swain B, Sharma N. Cryptococcus laurentii: An unusual cause for atypical pneumonia in hematological malignancy. J Mahatma Gandhi Inst Med Sci [serial online] 2020 [cited 2020 May 26];25:45-7. Available from: http://www.jmgims.co.in/text.asp?2020/25/1/45/282364




  Introduction Top


Cryptococcosis, an uncommon and invasive fungal infection, is caused by various species of encapsulated yeast of genus Cryptococcus, usually Cryptococcus neoformans, in immunocompromised patients.[1] Nonneoformans species, namely, Cryptococcus albidus, Cryptococcus laurentii, Cryptococcus adeliensis, and Cryptococcus humicolus were considered saprophytes and nonpathogenic to humans in the past. However, opportunistic infections associated with these species have been reported in the recent years.[2] The common forms of immune suppression include AIDS, steroid therapy, malignancies, immunosuppressive therapy, and organ transplantation.[3] Chronic lymphocytic leukemia (CLL) with prolymphocytic leukemia (PLL) is known to impair both cellular and humoral immunity, which leads to susceptibility to various infections. Neutropenia, chemotherapy, and steroid therapy are the other contributing factors.[1]

C. laurentii is a basidiomycetous-encapsulated yeast present in the pigeon droppings,[2] responsible for both deep-seated and superficial infections. It has recently been reported as a cause of fungemia, pulmonary, and cutaneous infections in humans.[2],[4],[5] Here, we present a case of pulmonary cryptococcosis due to C. laurentii in a patient with CLL and PLL.


  Case Report Top


An elderly 65 year male, a known case of CLL and PLL diagnosed 4 years back and on steroid and chemotherapy (prednisone and chlorambucil), presented to the Emergency Department of IMS and SUM Hospital with chief complaints of fever with chills and cough without expectoration for the past 5 days, headache and generalized malaise for 4 days, pleuritic chest pain, and breathlessness for 2 days. He had a similar history of on and off cough for the past 4 months for which he was taking medications prescribed by the local medical practitioner. He was a priest in a temple which was nested with pigeons. He was HIV seronegative and had no other relevant history.

On general physical examination, he was febrile, hemodynamically stable, and had oxygen saturation of 87% in room air. Respiratory system examination revealed decreased chest expansion on the left side with stony dull note on percussion on the left lower chest and diminished air entry on the left lower lung field on auscultation along with bilateral basal crepitations (left > right). Examination of the abdomen revealed Grade 2 splenomegaly. The rest of the systemic examination was essentially normal. With a provisional diagnosis of pneumonia with pleural effusion, he was admitted under the wing of medical oncology for further evaluation and management.

A chest radiograph revealed symmetrical, patchy, bilateral ground-glass opacification in the lower lung fields along with left-sided pleural effusion. A high-resolution computed tomography corroborated the above findings and revealed consolidation with air bronchograms and mild left pleural effusion with mediastinal and axillary lymphadenopathy suggestive of infective atypical pneumonia. The patient was started empirically on piperacillin/tazobactam and voriconazole and was shifted to intensive care unit as he developed respiratory distress.

On routine blood examination, the hemoglobin was 7.9 g% with total count of 16,500 with 58% lymphocytes, 27% neutrophils, and 17% monocytes. The peripheral blood smear showed a dimorphic picture with the presence of atypical lymphoid cells.

Blood, sputum (induced), and urine samples were sent for both bacterial and fungal culture to the department of microbiology. Blood and urine samples yielded no growth on culture. Sputum microscopy showed Gram–positive, spherical, capsulated yeast cells suggestive of Cryptococcus [Figure 1]. Gram-positive cocci in pairs and long chains were also seen which were considered as part of normal flora. The sputum was negative for acid-fast bacilli by Ziehl–Neelsen staining. Sputum culture at 48 hour revealed pure growth of l–2 mm size; smooth, cream, and mucoid colonies on blood agar; and larger but similar colonies on Sabouraud's dextrose agar with chloramphenicol (without cycloheximide) [Figure 2].
Figure 1: Gram stain of the sputum sample showing capsulated yeast cell

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Figure 2: Colonies of Cryptococcus on Sabouraud's dextrose agar

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Gram stain from the colony showed Gram–positive, spherical, capsulated budding yeast cells with narrow neck budding. Negative stain showed thin capsules surrounding the yeast cells. Urease production was also noted. Subsequent identification and confirmation of the isolate as C. laurentii was done by Vitek-2. The treatment was immediately changed to intravenous fluconazole. A repeat blood culture now showed the growth of Cryptococcus. The patient succumbed on the subsequent day after initiation of appropriate therapy due to respiratory failure and sepsis leading to multiorgan dysfunction syndrome.


  Discussion Top


Cryptococcus is a ubiquitous organism, commonly found in soil contaminated with pigeon droppings and is transmitted to humans through inhalation.[2] As our patient was a priest with the history of exposure to pigeons, it made him vulnerable to this infection. However, there are little data on the isolation of C. laurentii from the respiratory tract of immunocompromised patients. It is one of those few cases of pneumonia resulting from C. laurentii in the Indian cancer population.

Cryptococcosis is an important opportunistic infection, and most patients suffering from it have T-cell dysfunction.[2] Our patient was a known case of CLL and PLL and was being treated with chlorambucil and steroid. The predilection for cryptococcal infections in patients with CLL has been confirmed in the largest published case series by Kaplan et al.[6] High-risk predisposition for cryptococcal infection is found in people treated with purine analogs,[7] but our case did not have this treatment which makes it different from the rest.

Prognosis among patients with malignancy is much worse; treatment failure is high despite therapy in contrast to those with HIV and organ transplantation.[8] Our patient had all the unfavorable prognostic factors.

Successful outcome in patients treated with fluconazole and amphotericin B for pulmonary cryptococcosis has been reported.[9],[10] There is no validated correlation between in vitro antifungal susceptibility test results and treatment outcomes for C. laurentii.[2] Unfortunately, our patient died of rapid disease progression, so we were unable to assess the response to therapy.


  Conclusion Top


The present case is one of the few reports to describe pulmonary involvement by C. laurentii in patients suffering from hematological cancer. Pulmonary symptoms may be noncharacteristic, so a high index of suspicion is needed to diagnose cryptococcosis in such patients. Improvement in culture and identification techniques for early diagnosis can contribute to prompt initiation of specific antifungal agents for a better outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We are grateful to S“O”A Deemed to be University for their constant support and encouragement.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dizdar OS, Karakeçili F, Coşkun BN, Ener B, Ali R, Mıstık R. Fatal cryptococcal meningitis in a patient with chronic lymphocytic leukemia. Mediterr J Hematol Infect Dis 2012;4:e2012039.  Back to cited text no. 1
    
2.
Shankar EM, Kumarasamy N, Bella D, Renuka S, Kownhar H, Suniti S, et al. Pneumonia and pleural effusion due to Cryptococcus laurentii in a clinically proven case of AIDS. Can Respir J 2006;13:275-8.  Back to cited text no. 2
    
3.
Akcaglar S, Sevgican E, Akalin H, Ener B, Tore O. Two cases of cryptococcal meningitis in immunocompromised patients not infected with HIV. Mycoses 2007;50:235-38.  Back to cited text no. 3
    
4.
Banerjee P, Haider M, Trehan V, Mishra B, Thakur A, Dogra V, et al. Cryptococcus laurentii fungemia. Ind J Med Microbiol 2013;31:75-7.  Back to cited text no. 4
    
5.
Kamalam A, Yesudian P, Thambiah AS. Cutaneous infection by Cryptococcus laurentii. Br J Dermatol 1977;97:221-3.  Back to cited text no. 5
    
6.
Kaplan MH, Rosen PP, Armstrong D. Cryptococcosis in a cancer hospital: Clinical and pathological correlates in forty-six patients. Cancer 1977;39:2265-74.  Back to cited text no. 6
    
7.
Samonis G, Kontoyiannis DP. Infectious complications of purine analog therapy. Curr Opin Infect Dis 2001;14:409-13.  Back to cited text no. 7
    
8.
Kontoyiannis DP, Peitsch WK, Reddy BT, Whimbey EE, Han XY, Bodey GP, et al. Cryptococcosis in patients with cancer. Clin Infect Dis 2001;32:145-50.  Back to cited text no. 8
    
9.
Walsh TJ, Hiemenz JW, Seibel NL, Perfect JR, Horwith G, Lee L, et al. Amphotericin B lipid complex for invasive fungal infections: Analysis of safety and efficiency in 556 cases. Clin Infect Dis 1998;26:1383-96.  Back to cited text no. 9
    
10.
Yew WW, Wong PC, Wong CF, Lee J, Chau CH. Oral fluconazole in the treatment of pulmonary cryptococcosis in non-AIDS patients. Drugs Exp Clin Res 1996;22:25-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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