Title : Tb or not Tb - A cryptic case of pleural effusion in an immunocompromised host

Abstract:

Cryptococcosis, a fungal infection, represents a significant and potentially life-threatening condition primarily seen in individuals with compromised immune systems worldwide. The presence of pleural effusion as the sole clinical manifestation is one of the rarest clinical presentations of cryptococcal infection in cases of pulmonary cryptococcosis.
A 29-year-old man was admitted to the hospital presenting with fever and breathlessness that had persisted for over one month. The chest X-ray revealed a slight left pleural effusion, with no observable abnormalities in the pulmonary parenchyma. A test result for HIV was positive. The pleural fluid exhibited exudative characteristics with elevated ADA levels. He was initially empirically initiated on ATT in view of high clinical suspicion, exudative nature of pleural fluid and elevated ADA however the result for CBNAAT was negative. In view of persistence of fever beyond 48hrs after initiation of ATT other alternative diagnosis was sought. On day 14 of admission, the pleural fluid yielded a positive culture for cryptococcus neoformans. Consequently, the patient received a diagnosis of cryptococcal pleural effusion and ATT has been discontinued. The patient was administered Amphotericin B and fluconazole, resulting in a positive response with resolution of fever. Elevated serum CMV PCR copies were observed, and patients were treated with valganciclovir. The patient showed improvement and was discharged to continue follow-up on an outpatient basis for the initiation of HAART, which commenced after a period of three weeks. He has responded positively to therapy and is currently doing well.

Conclusion:
An exudative pleural effusion accompanied by an elevated ADA level in a patient with immunosuppression although highly suggestive of, may be incorrectly identified as tuberculosis. Cryptococcal infection, while uncommon, warrants consideration. Timely identification and treatment with antifungal medications are crucial to avoid unfavourable results.

Keywords:
cryptococcosis, Cryptococcus neoformans, retro positive, multilocus sequence typing (MLST), pleuritis

Biography:

Dr. Sukesh Gerard did his medical school training and residency at the St John’s Medical College and Hospital, Bangalore and graduated as MD in 2023. He then joined the department of Internal Medicine. He has since worked in the department over the last two years and was part of the research mentorship for undergraduates’ team. He has worked with several subspecialities and closely with the Infectious Disease Unit at the Institute and is part of the team analyzing the prevalence of Vaccine Preventable Infections in the state, a joint effort by the institute and the World Health Organization. He has several case reports detailing the rare presentations of multiple infectious diseases.