Blame It on the Birds: An Unusual Cause of Dyspnea in a Young Woman

1Good Samaritan Hospital, Cincinnati, OH

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 223

Case Presentation:

A 26‐year‐old woman with a medical history of asthma presented to the emergency department with a 3‐day history of nonproductive cough, dyspnea on exertion, diaphoresis, and right‐sided chest pain. She also noted an increased need for inhalers without improvement. Physical exam was significant for crackles noted in the right lung field. Chest x‐ray revealed patchy infiltrates in the right upper and lower lobes, with a right hilar predominance. Initial investigation showed elevated D‐dimer (1.89 mg/L). Computed tomography (CT) scan of chest was negative for pulmonary emboli but showed consolidation and ground‐glass opacity throughout the right lung and confluent lymph nodes in the upper right hilum measuring up to 2.4 cm. The patient was given a breathing treatment and 1 dose of intravenous (IV) levofloxacin. She was discharged home with moxifloxacin and was to follow up with her primary care physician (PCP). Eight days later, the patient returned with similar complaints. Physical exam was significant for tachycardia (heart rate 107). Chest x‐ray showed no significant change from the previous visit. She was discharged home with amoxicillin/clavulanate. The following day, she presented to her PCP feeling worse, appearing more ill, and was directly admitted to the hospital. Her physical exam was significant for tachycardia (heart rate 101–127). Chest x‐ray revealed worsened infiltrates throughout the right lung. She was started on IV ceftriaxone and azithromycin. On hospital day (HD) 3 her symptoms progressed; thus, itraconazole was empirically started and bronchoscopy performed. Because of progressive opacification of the lung, she underwent video‐assisted thoracoscopy and wedge resection of the upper and lower lobes of the right lung on HD 6. Biopsies revealed positive mucicarmine staining and histomorphologic features consistent with Cryptococcus neo‐formans. Amphotericin and flucytosine were then added. Further questioning revealed that she had recently moved apartments and the window air‐conditioner (AC) had a bird's nest on it. She was exposed daily to air from the AC for about a month.

Discussion:

Despite exposure of a large segment of the population to Cryptococcus, isolated pulmonary cryptococcal pneumonia rarely affects immunocompe‐tent patients. Humans are exposed to Cryptococcus by inhaling the basidiospore form of the fungus, rather than by human‐to‐human contact. Immune status is the only clear risk factor that determines symptom development. The most common symptoms include cough, chest pain, increased sputum production, fever, and weight loss. Diagnosis for pulmonary cryptococcosis includes histology, culture, radiography, and cryptococcal antigen.

Conclusions:

Although unusual, the possibility of a cryptococcal infection in immu‐nocompetent patients should be considered in a patient with a nonresolving pneumonia. This case illustrates the importance of a detailed history and physical exam, including targeted questions regarding animal exposure.

Disclosures:

M. Ahmed ‐ none; M. Afzal ‐ none; U. Kakumanu ‐ none; S. Price ‐ none; T. Patel ‐ none

To cite this abstract:

Ahmed M, Afzal M, Kakumanu U, Price S, Patel T. Blame It on the Birds: An Unusual Cause of Dyspnea in a Young Woman. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 223. https://www.shmabstracts.com/abstract/blame-it-on-the-birds-an-unusual-cause-of-dyspnea-in-a-young-woman/. Accessed December 10, 2018.

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