Thread by @WuidQ

#idgrandrounds
1/2
61M ESRD s/p kidney transplant 2016 (CMV D-/R-), on tac/pred, 6 mos progressive memory loss, falls, headache, blurred vision. No fever.
Traveled to southwest US, Malaysia, Thailand >10 yrs ago. Monogamous relationship.
@BradCutrellMD @Cortes_Penfield

2/2
Exam: disoriented, poor memory, ⬇️ proprioreception, supple neck.
Labs: macrocytic anemia
CXR: nonspecific small nodule
MRI: mild periventricular hyperintensity, panventriculomegaly

What are you DDX and suggested work-up? @TxID_Edu @jdcooperid @MohitHarshMD @k_vaishnani

@TxID_Edu @jdcooperid @MohitHarshMD @k_vaishnani 1/11
CASE RESOLUTION
Prior to transfer, managed in the dementia clinic.
LP was only done late: lymphocytic pleocytosis, elevated TP, glucose <20. Serum/CSF CrAg +, CSF +Cryptococcus neoformans.

Excellent work @Cortes_Penfield @jdcooperid @TxID_Edu @ShohamTxID @PVishnuRao1

2/11
The patient's indolent presentation made the diagnosis challenging prior to hospital transfer. Case is presented to highlight important learning points especially for the non-ID clinicians.

3/11
1⃣ Crypto in non-HIV, non-transplant: higher mortality compared to people living with HIV as shown by @IgeGeorgeMD @FungalDoc 👇 (green: HIV; red: transplant; blue: non-HIV, non-transplant) bit.ly/2RiW1zk

4/11
Higher mortality likely 2/2 delayed dx:
▪️ More atypical (more likely to be afebrile, headache is less common, lung/skin manifestations are more common, LP performed less) bit.ly/2Nv6KFM

👉 Thus, crypto in non-HIV, non-transplant needs higher index of suspicion

5/11
2⃣ Cryptococcal meningoencephalitis present subacutely; also chronic & progressive dementia:
▪️ 70M w/ 2 yrs memory loss & imbalance bit.ly/2FOZ2SG
▪️ 63M w/ 4 yrs imbalance & HCP bit.ly/2QVZbKp
▪️ 65M w/ 2 yrs cognitive decline bit.ly/36XMDYy

6/11
3⃣ Need to build new illness script to heighten suspicion for cryptococcosis. For example.

✔️ High index of suspicion in cirrhosis
✔️ Skin manifestations
✔️ Pneumonia

7/11
👉 Cirrhosis & crypto:
▪️ OR 8.5 for crypto meningitis, OR 23.8 for cryptococcemia bit.ly/35Y6HZr
▪️ High mortality bit.ly/2QX6hyk , in one case series, 100% bit.ly/2Rxxuqv
▪️ CNS > Pulmonary BUT 20% peritoneal bit.ly/36YxndM

8/11
👉 Derm manifestation of crypto:
▪️ Actually 3rd most common site after CNS and pulmonary
▪️ Wide variety (can mimic almost any skin condition) especially in immunocompromised hosts. Some noteworthy:

Necrotizing fasciitis👇 bit.ly/2NtQmoK

9/11
Derm and crypto continued..

Cellulitis 👇 bit.ly/2uSkWCg

10/11
Derm and crypto continued..

Umbilicated papules (molluscum contagiosum-like) 👇 bit.ly/30oLbf4

11/11
In summary, case of crypto w/ progressive dementia was presented. Dx was late. Highlights importance of high index of suspicion & modifying illness script to include other manifestations of Crypto.

Early dx/tx (& ID consult) is life saving bit.ly/2RjalI6.

11/11 extra
Do you have any other atypical manifestation of Crypto you'd like to share to the group? Feel free to comment @IDdocAdi @FranciscoMarty_ @FungalDoc @EmilyBlumbergMD @GermHunterMD @PaulSaxMD @CarlosdelRio7