Cryptococcal pneumonia in a HIV positive patient: a pre- and post-mortem view.

A 42-year-old man with no significant medical history presented to the emergency department with headaches and fever of three weeks duration. He had returned to the United States from a recent trip to Puerto Rico, where he reported multiple unprotected sexual contacts with men. One week prior to presentation, he was evaluated at an outside facility and was discharged with a diagnosis of Dengue fever. On further evaluation, ELISA testing for HIV was positive and was confirmed with Western Blot. His CD4+ cell count was 0.015 K/ uL. A lumbar puncture was performed and his cerebrospinal fluid was positive for cryptococcal antigen. On examination of the spinal fluid, encapsulated yeast-like forms were seen and cultures were positive for Cryptococcus neoformans. An anteroposterior chest radiograph revealed a 2.6 x 2.0 cm cavitary lesion in the right lower lobe. (Figure 1) The patient was admitted for further treatment. During his hospital course, he experienced seizure-like activity and became unresponsive. A non-contrast CT scan of the head at this time was non-diagnostic. He was transferred to the ICU; however, his condition deteriorated and he expired the day after admission. Cause of death was most likely due to septic shock in conjunction with an immunocompromised state. Autopsy was limited to the brain and lungs. In addition to congestion and edema, there was a cavitary lesion in the right lower lobe that contained mucopurulent material. (Figure 2) On microscopic examination of the cavitary lesion, encapsulated yeast-like forms that were positive for methenamine silver and mucicarmine were identified. (Figure 3) Autopsy also revealed evidence of cryptococcal meningitis.