The patient is a 50‐year‐old man with productive cough for 3 months, weight loss, and leg buckling with progressive thigh pain. He has a history of a ground‐level fall from a horse while working on a cattle farm 2 years prior to presentation. He relates he fell onto a tree, sustaining a puncture wound to his thigh from a tree branch. Initial leg imaging was negative for fracture. Updated imaging now revealed callous formation and oblique fracture of the distal femoral shaft with a “moth‐eaten” appearance. CT pulmonary angiogram demonstrated right upper lobe consolidation, 3 cm pulmonary nodule, mediastinal lymphadenopathy but was negative for pulmonary embolus. Additional laboratory studies revealed hyponatremia with a sodium of 119 mEq/L. On presentation the patient was alert and oriented but became increasingly confused and agitated over time. He was subsequently transferred to the cancer center due to concern of potential osteosarcoma or other malignancy. The patient underwent a left femoral intramedullary nail fixation and biopsy of periosseous tissue. Pathology confirmed Cryptococcus gattii osteomyelitis. Because of his confusion, there was concern for disseminated Cryptococcus. This is defined as evidence of disease in 2 noncontiguous sites or cryptococcal antigen by latex agglutination > 1:512. Blood cultures and cerebral spinal fluid were obtained and Cryptococcus gattii titer was noted at 1:4096. MRI of the brain showed hydrocephalus without focal lesions. HIV, RPR, acid‐fast bacilli and anaerobes were negative. The treatment plan for disseminated Cryptococcus included initial therapy with cefepime, daptomycin, and amphotericin B and subsequent treatment with amphotericin B and flucytosine for 4 weeks. This is to be followed by 1 year of voriconazole. By the time of discharge, his mental status improved to baseline and hyponatremia had resolved. Follow‐up blood cultures demonstrated clearance of crytococcal antigens and repeat CT thorax showed resolution of pneumonia.
C. gattii is an invasive fungal infection found in immumocompetent hosts. Although initially limited to the tropics and subtropics, it is now showing evidence of global distribution. In 2011, C. gattii was identified in all sections of the United States but was first identified in 1999 in the Pacific Northwest. It is found in decaying hollows of trees and branches in more than 50 tree species, also the air, soil, and water in heavily infested areas. C. gattii is introduced via spore inhalation or, as with this patient, traumatic injury, and tends to be insidious but virulent. It produces lung and brain lesions causing hydrocephalus and CNS deficits, leading to more neurologic complications and delayed therapy response. It is associated with poor outcome.
This case serves to illustrate the growing prevalence of C. gattii infection as well as raise awareness of this potential disease in otherwise healthy individuals.
To cite this abstract:Gruchow T, Palacio C, Eaton K, Carlin K. Cryptococcus Gattii: A Spreading Tropical Fungus. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 350. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/cryptococcus-gattii-a-spreading-tropical-fungus/. Accessed January 18, 2020.