B72-16 Double Jeopardy: Cryptococcal and Necrotizing Pneumonia Complicating Late Pregnancy

Abstract Cryptococcus is an invasive mycosis species found worldwide and is known for its opportunistic behavior. Mortality rates up to 25% have been noted in the maternal population. Most cases are diagnosed in the third trimester, and less than half of pregnancies are carried to term. The following case presents peripartum cryptococcal pneumonia complicated by pulmonary abscesses in an otherwise healthy female—highlighting immunologic and treatment considerations in this vulnerable population. A 23-year-old woman was initially admitted at 29 weeks 5 days gestation for treatment of community acquired pneumonia and discharged. She then presented 10 days later, at 33 weeks 4 days gestation, for persistent emesis, chest pain, fatigue, and productive cough. On presentation, she had tachycardia (HR120 bpm), tachypnea (RR 28), hypoxia requiring nasal cannula, and leukocytosis (WBC 18.5). The patient worked as a dialysis technician and denied sick contacts. A chest computed tomography (CT) angiography ruled out pulmonary embolism. However, it showed progression of multifocal pneumonia in the right lung with new right upper lobe nodular consolidations and right lower lobe gas locules. She was readmitted for sepsis secondary to necrotizing pneumonia. Early collaboration among the maternal fetal medicine, pulmonary-critical care, and infectious disease (ID) teams prompted admission to the intensive care unit for high-risk bronchoscopy with RLL bronchoalveolar lavage (BAL). BAL returned positive for Methicillin Sensitive Staph Aureus (MSSA) PCR. Labs confirmed a positive cryptococcal antigen (titer 1:256). Delivery was pursued given antifungal risks in pregnancy. Induction was completed with intravenous piperacillin-tazobactam and amphotericin B daily for seven days followed by maintenance oral fluconazole 400mg daily for six months. Upon discharge, ID followed serial labs and chest CTs. This case demonstrates the therapeutic considerations of this rare condition including balancing maternal health with fetal safety, immunologic changes, and the need for multidisciplinary input. Pregnancy, specifically in the third trimester, is considered a state of relative immunosuppression. While amphotericin B is classified as a category B drug and is the preferred treatment in the maternal population, it does cross the placenta and may put fetus at risk for renal dysfunction and electrolyte derangements. Fluconazole should be avoided in the first trimester due to teratogenic effects. Its safety in later trimesters is not well documented; however, it is recommended for use post-partum despite its excretion in breast milk. The decision to proceed with delivery should be individualized, and a risk-benefit discussion should occur between the treating teams and patient. This abstract is funded by: none