Crypto C Cocus

AN AIDS PATIENT WITH
CRYPTOCOCCUS
NEOFORMANS INFECTION
Ahmad Danial
Department of Internal Medicine

Dr. Soetomo Hospital – Airlangga Faculty of
Medicine
Surabaya 2018
Background
• The number of people with HIV/AIDS 

• Opportunistic infections are quite
common such as Cryptococcus
Neoformans infections
• The estimated number of people with
cryptococcosis reaches 1,000,000 people
per year and 625,000 of them die
((Jarvis, 2007; Brezendine, 2011;UNAIDS, 2013)

Background
The most common clinical presentation of

cryptococcal infections
• Meningoencephalitis
• Lung disease caused by cryptococcus
neoformans species is rarely reported
asymptomatic
(Chayakulkeeree M, 2006).
CASE
IDENTITY :
• Foto klinis pasien
Name : Mr. T
Sex : Male
Age : 43 yrs
Address : Surabaya
Occupation :
HISTORY
Chief complain: • No chest pain
• Dyspnea • Fever 2 weeks PTA
Present illness • No night sweating
• Dyspnea since 2 • Lost of appetite 4
weeks prior to months PTA
admission (PTA) • Weight loss 12 kgs in
• Cough 4 months
• Thick sputum • Oral ulcer+
• No headache or
seizure
HISTORY
Past illness:
• The history of DM,HT, and Tuberculosis
were denied
• Smoking and alcohol +
• History of drug abuse and free sex were
denied
• Was diagnosed with HIV at Soewandhie
Hospital 2 weeks PTA
Physical Examination
anemia (-)
GCS 346, somnolent ict (-)/ cyan (-)
/dysp (+)
Vital Sign:
BP 100/70 mmHg Ronchi + on 2/3
Pulse 111 bpm both hemithorax
Resp rate 30-32 tpm
Axillary temp 38,30 C
SpO2 97 % Within
normal limit
Within
normal limit
LABORATORY FINDINGS
CBC Chemistry Panel ABG Urinalysis
Hb 10,8 BUN 17 pH 7,52 Gluc -
HCT 33,3% Scr 0,98 pCO2 29 Bil -
MCV 93,4 GDA 93 pO2 52,2 Keto -
MVH 30,2 Alb 2,58 HCO3 24,2 SG 1,008
MCHC 32,4 SGOT 24 BE 1,0 Bld -
leuco 6510 SGPT 14 SO2 90,4% pH 6,9
Gran 85,6% D Bil 0,30 AaDO2 58,7 prot -
PLT 257000 T Bil 0,56 Nit -
Na 142 Leu trace
K 4,3 Color yellow
Cl 104 Clar clear
eri 0-2/lp
leu 0-2/lp
Supportive Examination
• cxr • Cor: within normal limit
• Pulmo: Reticulogranular
pattern in both hemithorax.
Trachea in the middle, left
and right costophrenicus
angle were sharp,. Soft tissue
does not appear
abnormalities. The visualized
bone looks good.
Supportive Examination
• Gambar ct scan
No hipodense / hiperdense lesion in the parenchymal

brain. No contrast enhancement. Sulcus and gyrus
seemed normal. The ventricular system and cysterna
are normal. Pons and cerebellum are normal. No
apparent abnormal calcification. No midline deviation
looks.
Consultation with Pulmonolgy
Department
• Suspicion of Bacterial Pneumonia with
pneumonitis cranii and respiratory failure
Consultation with Anesthesiology

Department
• Patients with respiratory failure due to lung
infection problems. However, the patient's
family refused to install ventilator.
Consulatation with Neurology

Department
• No neurologic deficit
Initial Assesment
• HIV/AIDS
• S. Pneumonia dd PCP
• Respiratory Failure
• Candidiasis Oris
• Hipoalbumin
Diagnostic Planning: blood and sputum culture, procalcitonin,
smear sputum gram, BTA, Gene X-pert, HIV 3 metode, CD4, ABG
serial, Albumin
Therapy:O2 Nonrebreathing mask 12 lpm, diit sonde 6x100cc,

Infus Nacl 0,9% 1500 cc/24 jam, Injeksi Ceftriaxone 2x1 gram,
Transfusi Albumin 20% 100 cc within 4hrs, cotrimoksazole forte
1x960 mg, per sonde paracetamol 3x500 mg, Nebul Combivent /8
hrs, Nystatin drop 4x6 gtt.
2nd day of treatment :
S: dyspnea+ cough + headache + pain while swallowing
O: BP: 110/70, HR: 98x/menit, RR :26 x/menit, t 37,60
HIV 3 metote reactive. CD4 absolut 5 cells/unit CD4 % 0.85% ABGpH 7.48 PCO2
31 PO2 93,2 HCO3- 22.5 BE 1.0 SO2 96.4%.
A: AIDS+Pneumonia dd PCP+Respiratory Failure+Candidiasis Oris+ Hipoalbumin
P:therapy still the same
5th day of treatment :
S: dyspnea+ cough +
O: BP: 110/60, HR: 88x/menit, RR :24-26 x/menit, t 37,60
hemoglobin 10.6 g/dL, hematokrit 35.2%, MCV 92.4 fL, MCH 30.2 pg, MCHC 32.4
g/dL, leukosit 8320/µL, neutrofil 78.8%, limfosit 15.7%, trombosit 262000/µL, GDA
116 mg/dL, albumin 2.89 ABG pH 7.47 PCO2 34 PO2 101,2 HCO3- 23.1 BE 1.0
SO2 96.6%. Gram sputum coccus gram postif staphylococcus hominis and yeast
cell yaitu cryptococcus neoformans. Blood culture yeast cell in the form of
cryptococcus neoformans. BTA negative.
A: AIDS+Cryptococcus Neoformans infection +Respiratory Failure+ Candidiasis
Oris+ Hipoalbumin
P:peroral fluconazole 1x 750 mg, peroral vip albumin 3x1 tablet, peroral duviral
2x1 tablet, peroral neviral 2x1 tablet. Others remains the same
S: dyspnea cough +
O: BP: 110/80, HR: 81x/menit, RR :26 x/menit, t 36,80
pH 7.44 PCO2 37 PO2 121,2 HCO3- 23.4 BE 1.0 SO2 97.6%. Hasil pemeriksaan
lateral flow assay (LFA) positif
A: AIDS+Cryptoccoccus Neoformans infection+Respiratory Failure
(improved)+Candidiasis Oris+ Hipoalbumin
P:O2 masker 6-8 lpm other therapy remains the same
S: dyspnea cough 
O: BP: 110/80, HR: 83x/menit, RR :20, x/menit, t 36,60
hemoglobin 11.2 g/dL, hematokrit 35.2%, MCV 92.2 fL, MCH 30.2 pg, MCHC
32.4 g/dL, leukosit 7610/µL, neutrofil 72.6%, limfosit 14.3%, trombosit 264000/µL,
GDA 131 mg/dL, albumin 3.12 g/dL.Hasil BGA pH 7.41 PCO2 38 PO2 121,9
HCO3- 23.3 BE 0.8 SO2 97.6%.
A: AIDS+Cryptoccoccus Neoformans infection+Respiratory Failure
(improved)+Candidiasis Oris+ Hipoalbumin
P:pro ambulatoir
Progress Note
• Cxr evaluation on • Cor : within normal
day 15th limit
• Pulmo :
reticulogranular
pattern in both
hemithorax
Outpation Clinic
S : cough +
O: BP : 110/80 HR : 83bpm RR : 20 t : 36,6
A: AIDS
Cryptoccoccus Neoformans infection
Respiratory Failure (improved)
Candidiasis Oris
Hipoalbumin (Improved)
P:peroral fluconazole 1x 200 mg peroral

duviral 2x1 tablet, peroral neviral 2x1 table
DISCUSSIONN
• Encapsulated, round-to-oval
yeast measuring 4-6 microns
with a surrounding
polysaccharide capsule
• The polysaccharide capsule,
composed mainly of
glucuronoxylomannan, is
thought to be the organism's
primary virulence factor
• The exopolysaccharides of
the capsule may contribute to
virulence by suppressing the
immune response, inhibiting
leukocyte migration, and
enhancing HIV replication
(Aberg & Powderly, 2006)

• Mortality of HIV-associated meningitis
patients caused by Cryptococcus is quite
high at around 10% -30%.
• T-cell-mediated immune defects (such as
people with AIDS) are predisposing
factors in 80% -90% of patients with
Cryptococcus infection
(Bicanic & Harrison, 2004)

(Antinori, 2013).
• Clinical presentations of
pulmonary cryptococcosis vary On This Patient
along the spectrum from
colonization to clinical
manifestations may show • dyspnea since 2 weeks PTA.
asymptomatic to severe • Worsened 3 days PTA .
pneumonia with respiratory • Not improved with rest.
failure. • Cough
• White sputum
• Symptoms are not specific, • No chest
characterized by cough, fever, • Fever 2 PTA.
dyspnea, pleuritic chest pain, • From physical examination, we
haemoptysis, and malaise, and get rhonki on 2/3 over left and
can not be used reliably to right lung field.
distinguish many pathogens • CXR Reticulogranullar pattern
capable of causing pneumonia in on both hemothorax
these patients. In patients • respiratory failure type 1.
starting antiretroviral (ARV)
therapy, a worsening of the
paradox of clinical symptoms
associated with immune
reconstitution inflammatory
syndrome (IRIS) may occur
(Brinzedine, et al,2011).
On this Patient :
• Radiological findings : single or CXR : Reticulogranullar pattern

multiple nodules, segmental or on both hemothorax
lobe consolidation, cavitary HIV 3 metote reactive. CD4
lesions, and diffuse interstitial absolut 5 cells/unit CD4 % 0.85%
patterns. Pleural effusions are
relatively rare.
• HIV-positive patients often show
pulmonary involvement as part of
a disseminated process that
occurs with a CD4 cell count
<100 cells / mL.
(Brinzedine, et al,2011).
• Any patients with HIV infection
presenting with subacute/ chronic
headache, particularly those who
are CD4-deplete, should be On this Patient:
investigated for CM. Lumbar
puncture should be performed to On the fifth day of treatment we
measure opening pressure, found the results of examination
cerebrospinal fluid (CSF) cell of gram sputum germicoccus
counts, biochemistry and culture, gram posap positive gram
CSF CrAg, Gram stain and India staphylococcus hominis and
ink, along with serum CrAg, yeast cell formation is
blood culture and chest X-ray. cryptococcus neoformans. The
CT or MRI brain scans are result of blood culture
helpful in assessing examination was adapted yeast
cryptococcomas, meningeal cell formation cryptococcus
inflammation, vasculitis and neoformans and we follow up with
ventricular compression. LFA examination. On the eighth
• The new lateral flow assay (LFA) day of treatment we got positive
for measuring cryptococcal LVA flow assay (LFA)
antigen designed as a point-of-
care test has performed well (>
95% sensitivity and 100%
specificity)
(Kabanda, 2014 ; Kohno, 2015)
Therapy
(Warkentien and Crum-Cianflone,2010).

SUMMARY
• t has been reported the case of a newly diagnosed 43-
I
year-old man with HIV and opportunistic infection of

Cryptococcus Neoformans.
• Mortality in HIV-infected patients with Cryptococcus is
high.
• Time to start antiretroviral therapy in HIV-infected
patients with cryptococcosis should be delayed up to 5
weeks after the start of antifungal therapy. Integrated
therapy of HIV and cryptococcosis includes antifungal
therapy, intracranial pressure management for
cryptococcal meningitis, and the provision of ARVs to
restore immune function is the key to success.

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AN AIDS PATIENT WITH

Department of Internal Medicine

• The number of people with HIV/AIDS 

((Jarvis, 2007; Brezendine, 2011;UNAIDS, 2013)

The most common clinical presentation of

No hipodense / hiperdense lesion in the parenchymal

Consultation with Anesthesiology

Consulatation with Neurology

Therapy:O2 Nonrebreathing mask 12 lpm, diit sonde 6x100cc,

P:peroral fluconazole 1x 200 mg peroral

(Aberg & Powderly, 2006)

(Bicanic & Harrison, 2004)

• Radiological findings : single or CXR : Reticulogranullar pattern

(Warkentien and Crum-Cianflone,2010).

year-old man with HIV and opportunistic infection of

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