B72-20 Mediastinal Lymphadenopathy Due to Disseminated Cryptococcus in a Patient With Newly Diagnosed HIV/AIDS

Abstract Background Disseminated cryptococcosis is a life-threatening opportunistic infection seen in advanced HIV/AIDS. While pulmonary and central nervous system involvement are common, mediastinal lymphadenopathy as a predominant manifestation is uncommon and may mimic tuberculosis or malignancy. Case Presentation A 44-year-old male with recently diagnosed HIV presenting with intractable nausea, vomiting, dysphagia, and 40-pound weight loss. Initial evaluation showed a CD4 count of 22 cells/µL with a viral load of 2,010,000 copies/mL. CT chest demonstrated an 11 mm cavitary nodule in the right upper lobe with marked mediastinal lymphadenopathy. Bronchoscopy with bronchoalveolar lavage and endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes revealed numerous encapsulated fungal organisms with narrow-based budding, morphologically consistent with Cryptococcus neoformans. The capsule stained positively with mucicarmine, Alcian blue, and PAS stains. AFB smears were negative, ruling out tuberculosis. Blood and cerebrospinal fluid cultures confirmed Cryptococcus neoformans, establishing disseminated cryptococcosis with fungemia, meningitis, pulmonary, and mediastinal lymph node involvement. The patient developed headaches and bilateral neuropathy secondary to elevated intracranial pressure, which improved following serial lumbar punctures further requiring lumbar drain. Ophthalmologic evaluation showed cryptococcal choroidopathy. He was treated with liposomal amphotericin B 300 mg IV daily and flucytosine 1500 mg orally every six hours for a 14-day induction phase. Valganciclovir was initiated for CMV viremia, and atovaquone for PCP prophylaxis. Antiretroviral therapy initiation was deferred to prevent immune reconstitution inflammatory syndrome. Discussion Mediastinal lymphadenopathy as a manifestation of cryptococcosis is rarely reported, particularly in comparison to tuberculosis or lymphoma, This case highlights the diagnostic value of endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) in identifying fungal pathogens from lymphatic tissue, allowing timely initiation of targeted antifungal therapy. The patient’s course illustrates need for aggressive management of elevated intracranial pressure and careful timing of ART to balance infection control and prevention of IRIS. Furthermore, this case highlights clinical spectrum of Cryptococcus neoformans in HIV, emphasizing that extrapulmonary and extraparenchymal disease can occur in the absence of extensive lung parenchymal involvement. Clinicians should maintain high suspicion for fungal infections in HIV patients with lymphadenopathy, especially in endemic regions or when tuberculosis testing is negative. Conclusion This case emphasizes an atypical presentation of disseminated cryptococcosis with predominant mediastinal lymphadenopathy, mimicking tuberculosis in advanced HIV. Accurate diagnosis through cytopathology and fungal cultures is essential to guide therapy and avoid inappropriate empiric treatment. This case reinforces the importance of considering cryptococcosis as differential diagnosis of mediastinal lymphadenopathy in severely immunocompromised individuals, broadening awareness of its variable manifestations. This abstract is funded by: none