Disseminated Cryptococcosis in an Immunocompetent Infant: Case Report of a Rare Manifestation

Cryptococcosis in immunocompetent individuals is rare and presents in a more severe clinical form than in immunosuppressed patients. We describe the case of a 9-month-old female infant, previously healthy, with no known comorbidities, referred to tertiary care after a presentation with hypotrophy, fever (38°C), multiple episodes of emesis and lip cyanosis. She evolved with grunting, unresponsiveness and hypoglycemia (capillary glucose: 34). She was admitted to the pediatric ICU with initially stable hemodynamic status, but with increased cardiac silhouette on chest radiograph and hepatomegaly with a palpable liver edge in the right iliac fossa on physical examination. Initial etiologic investigation included non-reactive NS1 antigen for dengue, negative serologies for viral hepatitis (HBsAg non-reactive, anti-HCV non-reactive, anti-HAV IgM non-reactive), CMV IgM non-reactive, EBV IgM non-reactive, herpesvirus IgM non-reactive, negative blood culture and negative respiratory viral panel. Admission laboratory tests showed anemia (Hb 8.1 g/dL), leukopenia (leukocytes 1,720), elevated transaminases (AST 323, ALT 100), direct hyperbilirubinemia, elevated cardiac enzymes (CPK 573; CKMB 55), coagulation abnormalities (PT/INR: 21/1.76) and metabolic acidosis with hyperlactatemia (lactate 8.6). Echocardiogram showed moderate pericardial effusion without signs of tamponade. Cerebrospinal fluid was normal, with negative tests and cultures. From day 5, the patient worsened, developing respiratory failure, progressive decline in level of consciousness, marked anasarca and abdominal distension, requiring central venous access and endotracheal intubation. On day 6, she had a cardiorespiratory arrest and was resuscitated after three cycles. The patient progressed with severe acute liver failure, encephalopathy, anuria and need for peritoneal dialysis. Empiric antimicrobials were instituted (ampicillin + sulbactam, acyclovir, metronidazole, later cefepime), corticosteroid therapy with dexamethasone, vasopressors (dopamine, dobutamine and adrenaline) and blood component support (plasma, red blood cells and platelets). On physical examination, there was marked jaundice (4+/4+), generalized edema, ecchymosis and distal necrosis of the 4th and 5th fingers of the left hand, and ascites. She evolved with multiple organ failure. On day 13, a new blood culture was requested; on day 14, the patient had another cardiorespiratory arrest with no recovery after 20 minutes of resuscitation maneuvers, evolving to death. The last blood culture result showed growth of Cryptococcus neoformans.