Associates' Presentations
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A Renal Transplant Patient With Fever

Ellie Farahabadi, M.D., Basil Varkey, M.D., Medical College of Wisconsin, Milwaukee, WI

A 45 year-old diabetic man with history of renal transplant sixteen years prior to admission presented with three weeks of fever, fatigue, nausea and headache. On physical exam, he had a low-grade fever, no nuchal rigidity, mild abdominal tenderness, and erythematous papules on both arms. Laboratory analysis showed normal WBC count and renal function. Chest x-ray and head CT were within normal limits. Spinal fluid analysis revealed a WBC count of 20 cells/mm³ and a lymphocytic pleocytosis. Diagnosis of disseminated cryptococcosis was made based on identification of cryptococcal antigen in spinal fluid, serum, and urine. Fungal culture confirmed the presence of Cryptococcus neoformans. The patient was treated with Amphotericin B and Flucytosine with resolution of symptoms and decreasing cryptococcal antigen titers in spinal fluid.

Cryptococcosis is a disease caused by the encapsulated yeast-like fungus Cryptococcus neoformans. The organism exists in soil and is present worldwide. Infection is acquired by inhalation of the unencapsulated yeast. Pulmonary cryptococcosis is rarely symptomatic and is usually a self-limiting disease in immunocompetent individuals. In patients with T-cell dysfunction there may be post primary dissemination with seeding of CNS, skin, eyes, urinary tract and bones. Clinical manifestations of disseminated cryptococcosis are insidious and include headache, fever, nausea, cough, dyspnea, arthralgias, and skin lesions. One third of patients with disseminated infection have abnormal chest x-rays. As in this case, lumbar puncture is key to making the diagnosis. Organisms are detected from spinal fluid by India ink examination, by assay for cryptococcal capsular polysaccharide or by culture. The disease is fatal if not treated. Amphotericin B is the treatment of choice, which may be given in conjunction with Flucytosine for synergy.

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