Puerpera with back pain and intermittent fever

Discussion

Cryptococcus sp. infection is common in immunocompromised patients. In this group, it is most commonly related to the use of immunosuppressant drugs (41%), systemic lupus erythematosus (16%), malignant pathologies (16%) and diabetes mellitus (14%) [1]. However, in this case, pulmonary cryptococcosis was diagnosed in a previously healthy, immunocompetent puerperal patient.

The incidence of pulmonary cryptococcosis among patients with negative serology for HIV is low, around 0.2–0.9 per 100 000 inhabitants [2]. For this pathology to become established, it requires some degree of cellular immune deficiency, represented by changes in the in T-cells, natural killer cells, polymorphonuclear leukocytes, macrophages and specific antibodies [3]. Changes in the immune system peak in the third trimester of pregnancy, only returning to normal 3–5 months post partum [4]. Another possible risk factor for the spread of fungal infection is increased levels of sex hormones (progesterone and oestrogen) [5]. However, although gestation is described as a potential immunosuppressant factor, there is still no clear evidence that this period is an isolated risk factor for this infection [6].

In the present case, the patient’s pulmonary symptoms started during the third trimester of pregnancy and, without successful treatment, evolved with worsening of the condition in the puerperal period.

The presence of back pain and fever during pregnancy suggests several differential diagnoses, including abdominal pathologies and cholecystitis, or an infectious pulmonary pathology such as tuberculosis, community-acquired pneumonia or endemic mycoses [7]. Conversely, the presentation of the lung disease may be isolated or disseminated. In a third of non-AIDS cases with pulmonary cryptococcosis, acute respiratory failure developed [8].

When a pulmonary cryptococcal infection is suspected, a number of different diagnostic procedures may be relevant. A sputum sample should be sent for cytological analysis, as this can lead to an immediate diagnosis. Bronchoscopy is the most accurate method of diagnosis, especially when combined with transbronchial biopsy [9]. In patients with isolated pulmonary infection, serum cryptococcal antigen is positive in 25–56% of cases. This antigen is considered a marker of local disease severity or increased spread of infection [10]. Another complementary examination is a CT scan of the chest, which may show the extent of disease involvement in the thorax and the presence of pleural or mediastinal lesions [11]. Diagnosis is often attained through biopsy of the lesion or material obtained from bronchoalveolar lavage [12].

In the case presented here, the absence of diagnostic findings on bronchoalveolar lavage made CT-guided core biopsy necessary. The finding was of the spherical or oval yeast forms of the fungus in this material. The pathology may also identify necrotising or non-necrotising granulomas in the infected tissue and, in chronic inflammation, the presence of lymphocytic infiltrate [13].

Most cases reported in the literature have been treated with amphotericin B and have shown good results for both the infant and the mother [4]. For limited and stable pulmonary cryptococcosis, regular monitoring and administration of fluconazole after delivery should be performed. For the patient in question, there was remission of symptoms and significant radiological improvement with the use of fluconazole 400 mg once daily for 18 months. Fluconazole therapy is also well established; the difference lies in the duration of drug use [14]. Amphotericin B is the preferred initial treatment for cryptococcal meningoencephalitis, disseminated disease or severe pulmonary cryptococcosis in pregnant patients. This drug is classified by the US Food and Drug Administration as a category B drug for use during pregnancy. Data from clinical use of amphotericin B for coccidioidomycosis have not shown teratogenicity or toxicity related to renal dysfunction in the mother or fetus. Switching to fluconazole is appropriate after childbirth [15].

In conclusion, cryptococcosis should be considered in the differential diagnosis of infectious pulmonary diseases in pregnant and post partum women whose initial presentation is chest pain and fever.