Pulmonary Cryptococcosis due to Cryptococcus laurentii Co-infection with Miliary Tuberculosis in Adolescent Patient in Indonesia: Case Report

Domas Fitria Widyasari; M Edwin Widyanto Daniwijaya; Siswanto Siswanto; Fita Wirastuti; Tri Wibawa

doi:10.22146/ahj.v7i2.110936

Pulmonary Cryptococcosis due to Cryptococcus laurentii Co-infection with Miliary Tuberculosis in Adolescent Patient in Indonesia: Case Report

https://doi.org/10.22146/ahj.v7i2.110936

Domas Fitria Widyasari^(1*), M Edwin Widyanto Daniwijaya⁽²⁾, Siswanto Siswanto⁽³⁾, Fita Wirastuti⁽⁴⁾, Tri Wibawa⁽⁵⁾

(1) Department of Microbiology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta
(2) Department of Microbiology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta
(3) Department of Physiology, Faculty of Medicine-Public Health and Nursing, Universitas Gadjah Mada
(4) Department of Pediatric, Faculty of Medicine-Public Health and Nursing, Universitas Gadjah Mada
(5) Department of Microbiology, Faculty of Medicine-Public Health and Nursing, Universitas Gadjah Mada
(*) Corresponding Author

Abstract

Background: Non-neoformans cryptococci were previously considered to be saprophytes and nonpathogenic to humans. Cryptococcus laurentii is commonly found in the environment and pigeon feces and has been reported to be an emerging human fungal pathogen that causes infection in the immunocompromised host. Here, we report a unique case of pulmonary cryptococcosis coinfection with Miliary Tuberculosis.

Case: A 14-years old adolescent underweight boy was admitted to the Emergency Unit with the chief complaint of fever, cough, chest pain, breathlessness, night sweats, malaise, and weight loss. He was referred from Public Health Center in Sleman Yogyakarta with Miliary Tuberculosis and consumed six weeks of fixed-dose combinations of the first-line anti-tuberculosis drug. Microbiology culture of good quality patient sputum revealed Cryptococcus laurentii along with Klebsiella oxytoca. The patient was diagnosed with Pulmonary Cryptococcosis. The patient's symptoms, especially fever and chest pain, were not improved by oral Fluconazole 200 mg treatment. However, he had an excellent response to Levofloxacin 500 mg during hospitalization and oral Fluconazole therapy at 400 mg/day for eight weeks. After eight weeks of Fluconazole treatment, the patient got well, and then Fluconazole was stopped. Anti-tuberculosis was treated for six months, and no recurrence was found.

Conclusion: This article reports the rare pulmonary involvement of Cryptococcus laurentii in adolescent patients with Miliary Tuberculosis patient in Indonesia. A high degree of pulmonary mycosis suspicion and techniques improvement for respiratory specimen collection, culture, and identification contribute to early diagnosis and fungal infection treatment. In addition, interprofessional discussion can improve patient treatment and outcomes.

Keywords

Cryptococcus laurentii, co-infection, fluconazole, miliary tuberculosis

Full Text:

PDF

References

May RC, Stone NR, Wiesner DL, Bicanic T, Nielsen K. Cryptococcus: from environmental saprophyte to global pathogen. Nat Rev Microbiol. 2016;14(2):106-17.
Khawcharoenporn T, Apisarnthanarak A, Mundy LM. Non-neoformans cryptococcal infections: a systematic review. Infection. 2007;35(2):51-8.
Huang H, Pan J, Yang W, Lin J, Han Y, Lan K, et al. First case report of Cryptococcus laurentii knee infection in a previously healthy patient. BMC Infect Dis. 2020;20(1):681.
Shankar EM, Kumarasamy N, Bella D, Renuka S, Kownhar H, Suniti S, et al. Pneumonia and pleural effusion due to Cryptococcus laurentii in a clinically proven case of AIDS. Can Respir J. 2006;13(5):275-8.
Wahyuningsih R, Adawiyah R, Sjam R, Prihartono J, Ayu Tri Wulandari E, Rozaliyani A, et al. Serious fungal disease incidence and prevalence in Indonesia. Mycoses. 2021;64(10):1203-12.
Cryptococcus laurentii [Internet]. The MycoBank Engine and Related Databases. Available from: https://www.mycobank.org/page/Simple%20names%20search.
Hajjeh RA, Conn LA, Stephens DS, Baughman W, Hamill R, Graviss E, et al. Cryptococcosis: population-based multistate active surveillance and risk factors in human immunodeficiency virus-infected persons. Cryptococcal Active Surveillance Group. J Infect Dis. 1999;179(2):449-54.
Pappas PG. Cryptococcal infections in non-HIV-infected patients. Trans Am Clin Climatol Assoc. 2013;124:61-79.
Yu JQ, Tang KJ, Xu BL, Xie CM, Light RW. Pulmonary Cryptococcosis in non-AIDS patients. Braz J Infect Dis. 2012;16(6):531-9.
Chang CC, Sorrell TC, Chen SC. Pulmonary Cryptococcosis. Semin Respir Crit Care Med. 2015;36(5):681-91.
Abbas AK, Lichtman. AH, Pillai S. Cellular and molecular immunology. Elsevier Health Sciences; 2014.
Setianingrum F, Rautemaa-Richardson R, Denning DW. Pulmonary Cryptococcosis: A review of pathobiology and clinical aspects. Med Mycol. 2019;57(2):133-50.
Miceli MH, Diaz JA, Lee SA. Emerging opportunistic yeast infections. Lancet Infect Dis. 2011;11(2):142-51.
Lui G, Lee N, Ip M, Choi KW, Tso YK, Lam E, et al. Cryptococcosis in apparently immunocompetent patients. QJM. 2006;99(3):143-51.
Silva DL, Peres NTA, Santos DA. Key fungal co-infections: epidemiology, mechanisms of pathogenesis, and beyond. mBio. 2025;16(5):e0056225.
Roncaglio R, Bierhals DV, Andrade EF, Blan BDS, Buffarini R, Von Groll A, et al. Investigation of invasive fungal infection in tuberculosis/human immunodeficiency virus co-infected patients. Med Mycol. 2025;63(6).
Godbole G, Gant V. Respiratory tract infections in the immunocompromised. Curr Opin Pulm Med. 2013;19(3):244-50.
Jameson JL, Fauci AS, Kasper D, Hauser S, Longo D. Pneumonia, Bronchiectasis and Lung Abscess. Harrison's Principles of Internal Medicine. 20 ed. United States: McGraw-Hill, 2020.
Deng H, Zhang J, Li J, Wang D, Pan L, Xue X. Clinical features and radiological characteristics of pulmonary cryptococcosis. J Int Med Res. 2018;46(7):2687-95.
Jain S, Mahajan V, Kumar A. Unusual case of coexistent pulmonary Cryptococcosis and tuberculosis in an immunocompetent host. Indian J Tuberc. 2017;64(3):228-31.
Sawai T, Nakao T, Koga S, Ide S, Yoshioka S, Matsuo N, et al. Miliary tuberculosis with co-existing pulmonary Cryptococcosis in a non-HIV patient without underlying diseases: a case report. BMC Pulm Med. 2018;18(1):6.
Nabaei G, Afhami S. Disseminated cryptococcosis and active pulmonary tuberculosis co-infection in an otherwise healthy adult. Iran J Neurol. 2015;14(3):174-6.
Suresh CS, Ninan MM, Zachariah A, Michael JS. Cryptococcosis with Tuberculosis: Overlooked Co-infections. J Glob Infect Dis. 2021;13(3):139-41.
Chomicki J. Coexistence of pulmonary tuberculosis with pulmonary and meningeal Cryptococcosis. Report of a case. This chest. 1966;50(2):214-6.
Fang W, Zhang L, Liu J, Denning DW, Hagen F, Jiang W, et al. Tuberculosis/cryptococcosis co-infection in China between 1965 and 2016. Emerg Microbes Infect. 2017;6(8):e73.
Musabende M, Mukabatsinda C, Riviello ED, Ogbuagu O. Concurrent cryptococcal meningitis and disseminated tuberculosis occurring in an immunocompetent male. BMJ Case Rep. 2016;2016.
Leber AL. Clinical Microbiology Procedures Handbook. Washington, DC: ASM Press, 2016.
Miller JM, Binnicker MJ, Campbell S, Carroll KC, Chapin KC, Gilligan PH, et al. A Guide to Utilisation of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for Microbiology. Clin Infect Dis. 2018;67(6):e1-e94.
Perfect JR, Dismukes WE, Dromer F, Goldman DL, Graybill JR, Hamill RJ, et al. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis. 2010;50(3):291-322.