B72-22 Disseminated Cryptococcus Infection in a Steroid-Dependent Michigan Patient

Abstract Introduction This case involves a 52-year-old female with disseminated cryptococcal infection in the setting of chronic hydrocortisone use for adrenal insufficiency. Description of case A 52-year-old woman with Addison’s disease on chronic hydrocortisone presented with worsening shortness of breath and cough. She previously had numerous emergency department visits and admissions for complaints such as chest pain and shortness of breath. She initially presented to the emergency department with a one-week history of nonproductive cough and dyspnea. CT angiography ruled out pulmonary embolism and demonstrated “diffuse bilateral centrilobular and peribronchial ground-glass opacities and nodules similar to prior imaging, consistent with stable chronic lung disease”. She was discharged after symptomatic management but was admitted a week later due to chest pain, chest x-ray at this time showed bilateral moderate interstitial prominence with ground-glass opacity. These findings were deemed chronic, and she was discharged after her workup for chest pain was unremarkable. Two weeks later, she was hospitalized for worsening dyspnea; CT revealed increased peribronchovascular consolidation and coalescent nodules with perilymphatic distribution and smooth interstitial septal thickening, concerning for suspected sarcoidosis progression. She was discharged with pulmonology follow-up for suspected sarcoidosis, which she was unable to attend due to transportation issues. Three weeks later, she was readmitted with progressive dyspnea and productive cough, worsening since discharge. CT at this time showed “bilateral peribronchial airspace opacities with bronchiectasis and increased consolidation in the left lower lobe”. Bronchoscopy was pursued given the patient’s progressive changes and difficulties arranging outpatient bronchoscopy. Biopsies obtained during bronchoscopy demonstrated benign bronchial mucosa with mild chronic inflammation. Blood cultures drawn at the start of this admission grew Cryptococcus neoformans in one of two bottles, with serum cryptococcal antigen titer at 1:5. CSF studies and HIV testing were negative. Amphotericin B was initiated and transitioned to oral fluconazole. Patient was discharged following improvement. Outpatient outcome is pending. Discussion Cryptococcus is an opportunistic fungal pathogen that can mimic sarcoidosis or other granulomatous lung diseases. This case highlights the challenge of distinguishing sarcoidosis progression from disseminated opportunistic fungal infection in immunocompromised patients. Although cryptococcus is classically associated with the Pacific Northwest, this case demonstrates that disseminated infection can arise outside endemic regions. Radiographic worsening initially attributed to sarcoidosis progression was ultimately due to pulmonary cryptococcosis, which was likely exacerbating her underlying lung pathologies. Clinicians should maintain suspicion for opportunistic fungal infections in steroid-treated patients with atypical or progressive pulmonary findings. This abstract is funded by: None