Initial Diagnosis of Immunosuppression Due to Vertically Acquired Hiv in a Young Child: Disseminated Cryptococcosis Mimicking Tuberculosis

Cryptococcosis is an endemic fungal disease prevalent in the tropics and is responsible for most neuroinfections in adults immunosuppressed by the Human Immunodeficiency Virus (HIV), but with rare cases in the 3–5-year age group. A female child from the Midwest region of Brazil had recurrent infections – including pneumonias – from the age of 3 years until being diagnosed with HIV at age 4. Prenatal care had not been performed, and both parents also tested positive for HIV at the time of the child’s diagnosis. She was admitted the same day to a reference hospital for infectious diseases for investigation of a wasting syndrome and diarrhea. Her CD4+ T-cell count was 25 cells/mm³. Chest computed tomography showed areas of consolidation with cavitation with thickened walls in the left upper lobe suggestive of tuberculosis, and lymphadenopathy. An extensive search for mycobacteria was performed using Interferon Gamma Release Assay (IGRA), tuberculin skin test, lateral flow urine assay for lipoarabinomannan (LAM) antigen, smear microscopy and rapid molecular test for tuberculosis in gastric lavage, all of which were negative. In the search for differential diagnoses, serologic tests for fungi were requested, and the latex agglutination test for cryptococcosis in serum was positive with a titer of 1:1024. To rule out disseminated disease, even in the absence of neurologic abnormalities, we performed lumbar puncture and cerebrospinal fluid analysis showed a titer of 1:512 on the same test. CSF fungal culture demonstrated growth of Cryptococcus neoformans var. neoformans. Other serologies for histoplasmosis, syphilis and hepatitis were negative. Given pulmonary, hematologic and neurologic involvement, this was a case of disseminated cryptococcosis. Liposomal amphotericin B plus fluconazole were administered in the induction phase, followed by fluconazole for consolidation and maintenance. The patient is currently in outpatient follow-up, with normal neuropsychomotor development and on regular antiretroviral therapy. Although routine screening for cryptococcosis is not recommended in children with vertically transmitted HIV according to North American guidelines, we present a rare case of disseminated disease due to Cryptococcus neoformans in a young child, with a high risk of future sequelae had appropriate treatment not been initiated in a timely manner.