S1719 An Unusual Case of Cryptococcal Colitis in an HIV Patient

Introduction: Cryptococcus neoformans is a capsulated organism that causes opportunistic infections in those with HIV or immunocompromised states. It commonly causes neurological and systemic infections. Chronic gastrointestinal symptoms are a rare presentation, with only 28 cases reported in the past 20 years. We present a case of cryptococcal colitis that then evolved into disseminated disease. Case Description/Methods: A 56 year old healthy male presented to the emergency department for intractable nausea, vomiting and generalized abdominal pain for three days. For the past year he also experienced watery diarrhea, night sweats and a 33 pound weight loss. He was previously hospitalized in a different facility 2 weeks prior, and was started on prednisone for suspected polymyalgia. On admission, laboratory results were as follows: hemoglobin 12.1 g/dL; white blood cell 8.2 cells/mm3; platelet count 190,000/ mm3; total protein: 9.1 g/dL; ferritin >1747 ng/mL; CRP >16 mg/dL. CT abdomen and pelvis without contrast was unremarkable. He underwent an EGD and sigmoidoscopy in our facility. EGD was consistent with mild, superficial gastritis and duodenitis. Sigmoidoscopy revealed multiple, small 2-3 mm ulcerated lesions, with raised borders and depressed base that was covered with fibrinous material in the sigmoid and rectum. Ulcers were biopsied, and pathology report with periodic acid–Schiff (PAS), GMS and Alcian blue highlight yeast like forms, with morphology raising differential diagnosis of cryptococcus which would be rare in this context. In the following days, blood cultures grew yeast , and serum cryptococcal antigen was positive. He was then tested and found to be positive for HIV, with a CD4 count of 13. He was started on amphotericin B and fluconazole, however despite all efforts, passed away 8 days later. Discussion: Gastrointestinal involvement, even in disseminated infection, is very rare and can mimic other processes such as malignancy. Gastrointestinal cryptococcal infection tends to cause chronic diarrhea, fever, and generalized abdominal pain. The most frequent location is in the small bowel, and the most common findings on endoscopy include ulcers, perforations and mucosal patch injuries. Combination antifungal therapy with amphotericin B and fluconazole is recommended and are superior to monotherapy, particularly with disseminated infection or CNS involvement. It is the preferred treatment to avoid complications and recurrence, however depending on intestinal compromise surgery may be necessary.