Comments
INITIAL SYMPTOMS:
In immunocompetent patients: diarrhea lasting 2-28 days that may be associated with abdominal pain, nausea, myalgias, fatigue, headaches, and low grade fever; [Cohen, p. 1881]
FINDINGS:
Immunocompromised patients with this infection usually present with subacute or chronic meningitis. [CCDM, p. 134] Cryptococcosis is an opportunistic infection. Patients usually present with pneumonia, meningitis, or lesions of the skin, bone, or other organs. Immunocompetent patients often have only a self-limited respiratory infection. Fever is usually low-grade or absent in meningitis patients. Symptoms of meningitis are usually nonspecific--e.g.., headache, visual impairment, confusion, and agitation. Blindness may result from brain swelling and optic nerve injury. [Merck Manual, p. 1329] In disseminated cryptococcosis, skin lesions are common. Skin lesions are highly variable: papules (may resemble molluscum contagiosum), purpura, vesicles, and rashes. [Harrison ID, p. 1083-4] Among HIV-negative patients with cryptococcosis, about 20% are healthy without chronic disease or immunosuppression. In a review of 266 HIV-negative patients, 36% had only pulmonary involvement, and 51% presented with CNS disease. One third of normal hosts with cryptococcosis are asymptomatic and diagnosed because of abnormal chest x-ray findings (single or multiple nodules). Symptoms of CNS disease include headache, fever, lethargy, cranial nerve palsies, coma, and memory loss. Cryptococcemia may be common in some countries with high AIDS prevalence, but it rarely leads to shock. [PPID, p. 2936-42] In patients with pulmonary disease, cavitations are rare. [ID, p. 2207] Cryptococcosis is one of the uncommon causes of nodular lymphangitis; [Am Fam Physician 2001;63:326-32]
EPIDEMIOLOGY:
The fungus is commonly found in pigeon droppings, but no case clusters associated with this particular exposure have been reported. [CCDM, p. 135] Grows in gut of pigeons and in dried pigeon droppings; [Wallach, p. 576] Cryptococcal infection is common, but cryptococcal disease is relatively rare in immunocompetent people. Some infections produce a state of latency. [Harrison ID, p. 1082-3] Cryptococcosis is no longer common in AIDS patients in the US and Europe, but occurs in as many as 30% of AIDS patients in Africa. [Cecil, p. 1983] An ongoing outbreak of cryptococcosis (C. gattii) has been reported on Vancouver Island in British Columbia. C. gattii is associated with eucalyptus and a variety of coniferous trees. [PPID, p. 2936] C. gattii is found in Australia and Southeast Asia where it is associated with eucalyptus trees. [Cecil, p. 1983]
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