Hospital Course -- Severe Headache and Fever

Hospital Course:

This 55 year-old man presented to the emergency room at Presbyterian University Hospital with a chief complaint of "I have a severe headache and fever". The patient had been seen one week prior to presentation by his local physician with the complaints of headache and low grade fever. Two days prior to presentation at Presbyterian University Hospital he was seen in the emergency room at an outside hospital complaining of worsening of his headache and fever. While at that hospital, he was seen by the infectious disease service and a lumbar puncture was performed showing 169.7 mg/dl of protein, 38 mg/dl of glucose, and 1,464 white cells/ mm3. The cerebrospinal spinal fluid differential was noted for 100 neutrophils but no bacteria. Cryptococcal Antigen testing performed on cerebrospinal fluid resulted in a titer of 1:256. He was started on multiple antibiotics and transferred to Presbyterian University Hospital for further medical management.

Past Medical History:

1. Bursitis of Left shoulder for one year treated by hydrocortisone injections, once every three months by an outside physician prior to presentation.

2. Orthotopic Liver Transplant in 1992 for cirrhosis secondary to alcohol use.

3. Cadaveric Renal Transplant in 1994 for chronic renal failure secondary to glomerulonephritis.

4. Hypertension.

Physical Examination:

Physical examination showed a tired, middle aged, man in no apparent distress. His temperature was 38.5 degrees C with stable vital signs. His left shoulder was tender to palpation and movement.

RADIOGRAPHIC FINDINGS

Cryptococcal antigen testing performed on blood showed a titer of 1:32. Treatment with Amphotericin B and 5-flucytosine was started. Irrigation and debridement of the soft tissue abscess with debridement and excision of the left distal clavicle was performed. Tissue was sent for culture and for histologic sections.

Cultures:

Culture at 35 degrees C on 5% sheep blood agar and Sabouraud's dextrose agar grew slightly convex mucoid colonies with smooth edges. On cornmeal-Tween 80 agar round, dark walled, narrow neck budding yeast, without hyphae were identified. India ink stain of the colonies revealed encapsulated yeast with narrow based budding. The organism was presumptively identified using the rapid urease test and confirmed using the API 20C (bioMerieux).

Histology:

The tissue submitted consisted of fibroadipose tissue, acute inflammatory exudate, necrotic bone, and granulomatous inflammation. Numerous encapsulated yeast forms were found lying within pools of mucus. The organisms have the classical "poached egg" appearance described for this organism. Several narrow based budding yeast were identified and are highlighted by the mucicarmine stain.

Final Diagnosis