![]() Urinalysis showed moderate leukocyte esterase, negative nitrites and 135 WBCs per high powered field. Repeat blood and sputum cultures were negative. His WBC count was 2690 cells/mcL with an absolute neutrophil count of 960 cells/mcL and absolute lymphocyte count of 750 cells/mcL. On day 26, the patient was noted to be transiently somnolent with no other localizing symptoms. Repeat urine samples were not immediately obtained. He was transferred to Brigham and Women’s Hospital in Boston, MA on day 11 for ongoing management of his AML. His course was complicated by disseminated intravascular coagulation, acute kidney injury, and tumor lysis syndrome for which he was stabilized with transfusions, rasburicase, and hydroxyurea. ![]() He was started on empiric vancomycin and ceftazidime for a urinary tract infection and presumed bacterial pneumonia. CT scan of the abdomen showed stable known left hydronephrosis. Urine antigen testing for Streptococcus pneumoniae and Legionella were negative.ĬT scan of the chest showed consolidative opacities in the left upper and right lower lobes concerning for multifocal pneumonia. Sputum and blood cultures taken on admission were negative. His urinalysis revealed moderate leukocyte esterase, > 50 WBCs per high powered field, and moderate budding yeast identified as non- Candida albicans yeast by germ tube test without further identification due to laboratory protocol. Peripheral flow cytometry revealed new acute AML with myelomonocytic differentiation. His white blood cell (WBC) count was 57,000 cells/mcL with 23% blasts. His laboratory workup was notable for hypoglycemia (glucose 22 mg/dL), a creatinine of 1.5 mg/dL (baseline 1.4 mg/dL), and evidence of malignant transformation to acute myeloid leukemia (AML). On presentation he was hypothermic (31 ☌), bradycardic (HR 40 bpm), and hypotensive (systolic blood pressure was 80 s-90 mmHg). He had no recent or remote travel outside of the New England area. Two weeks prior to his hospitalization, he reported receiving cephalexin at a local clinic for a urinary tract infection (no culture data available), however he continued to experience urinary frequency and pain. neoformans isolated only from urine identified initially by MALDI-TOF MS.Ī 77-year-old Caucasian man with a long-standing history of high-risk myelodysplastic syndrome with systemic mastocytosis and benign prostatic hyperplasia was admitted to an outside hospital in the Boston (USA) area with several weeks of fatigue, somnolence, weakness, weight loss, and worsening nocturia. ![]() ![]() Cryptococcus may be missed from urine in laboratories that do not routinely identify all yeasts in urine cultures, as yeast is frequently a commensal or non-pathogenic organism in urine samples, particularly in patients with indwelling Foley catheters. There are no FDA approved CrAg assays for urinary samples. Additionally, the use of highly sensitive and specific serum and cerebrospinal fluid (CSF) lateral flow antigen assays to detect Cryptococcal capsular antigens from clinical samples have become important non-culture based diagnostic tools. Increasingly, the use of proteomic techniques such as MALDI-TOF MS and DNA sequencing of the internal transcribed spacer (ITS) region of the nuclear ribosomal DNA have replaced traditional phenotypic methods for identification from culture. neoformans is typically opaque to white and mucoid appearing on blood agar, while strains lacking capsules may appear dry. Though colony morphology is not a specific diagnostic feature, C. neoformans growing from clinical samples traditionally involves routine microbiology workup including specific staining techniques along with selective and differential media. One retrospective study in an 800-bed hospital over 12 years found an incidence of 0.56 patients per 100,000. Cryptococcuria is a rare clinical finding. Once inhaled, pulmonary infection can lead to hematogenous spread, most often to the central nervous system but occasionally to skin, bone, and rarely the prostate or bladder. The cryptococcal polysaccharide capsule is its main virulence factor, allowing it to evade host immunity and readily disseminate. Cryptococcus neoformans is a free living saprobic encapsulated yeast that is ubiquitous in the environment and typically causes infection in patients with immunocompromising conditions such as HIV, hematologic malignancy, or organ transplantation.
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