(1141) Sarcoid-Like Reaction to Disseminated Pulmonary Cryptococcosis in an Immunocompromised Vaper

Introduction: Cryptococcus neoformans is an opportunistic yeast that most commonly presents as a pulmonary infection with rare dissemination in immunocompromised hosts. Sarcoid-like reactions (SLRs) are typically reported in patients with malignancy, likely secondary to an immune response to tumor cells. To our knowledge, this is only the second reported case of pulmonary cryptococcosis causing a SLR.

Description: A 38-year-old male vaper with ulcerative colitis presented to the ED with pleuritic chest pain, dyspnea, and productive cough. Chest imaging revealed right upper lobe nodular, ground glass, reticular infiltrates and right hilar adenopathy. He was admitted for community-acquired pneumonia treatment. He developed respiratory distress, prompting bronchoscopy, which visualized tracheobronchial erythema. Wash cytology revealed fungal spores and long, filamentous bacteria concerning for Nocardia infection, and endobronchial biopsy revealed nonspecific fibrosis. He was transitioned to trimethoprim-sulfamethoxazole and fluconazole, which was discontinued the next day due to uncertain significance of the fungal spores. Unfortunately, his dyspnea worsened with declining oxygen saturations. Wash culture grew c. neoformans, and serology was positive for cryptococcal blood antigen. High-dose IV fluconazole was started, and he began to improve. Repeat bronchial wash cultures remained positive for cryptococcus, with biopsy significant for noncaseating granulomas with fungal elements. Sarcoidosis was ruled out as he did not exhibit hypercalcemia, elevated alkaline phosphatase, hypergammaglobulinemia, or systemic symptoms. Other diagnoses including ANCA vasculitis, mycobacterial infection, and primary immunodeficiencies were ruled out. The patient continued to improve, and after a 19-day hospital stay, he was discharged with fluconazole and pulmonary follow up.

Discussion: This is a rare case of a vaper with disseminated pulmonary cryptococcosis causing a SLR of the lung. Cryptococcal infection should be considered as a cause of SLR and differentiated from sarcoidosis for antifungal treatment. Further investigation into the association of E-cigarette or vaping product use-associated lung injury (EVALI) with pulmonary cryptococcosis is also needed and currently lacking in published literature.