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Patients with pulmonary cryptococcosis present with clinical pictures similar to other well-known diseases such as septic pulmonary emboli or choriocarcinoma. Treatment with triazole antifungal therapy yielded favorable results in our patient with this rare condition.

INTRODUCTION: Cryptococcal pneumonia is an opportunistic fungal infection caused by Cryptococcus neoformans. Many cases initially present in the lungs of those suffering from HIV/AIDS, diabetes, or on chronic immunosuppressants1. We present a case of a 28-year-old woman with no prior medical history who develops a severe case of cryptococcal pneumonia with factors of exposure or risk.CASE PRESENTATION: 28-year-old female with no prior medical history presents in the setting of a productive cough with yellow-brown sputum for 2 weeks that increased with frequency and severity. The patient presented to the emergency department and an initial computed tomography (CT) angiogram of the chest was performed that revealed a significant left lower lobe pneumonia, leading to her admission (Figure 1). The patient was initially started on levofloxacin and linezolid; however, MRSA, blood and sputum cultures, viral panel, HIV, and Covid-19 tests were all negative. A bronchoalveolar lavage was performed which also had negative cultures and cytology. The patient began to develop fevers, and a cryptococcal antigen was tested that was positive. The patient was started on fluconazole IV, and underwent a successful left video-assisted thoracoscopic surgery (VATS) with lower lobe resection, with the pathology revealing non-necrotizing and focal necrotizing granulomas. A GMS stain revealed numerous yeast forms with narrow based budding, morphologically consistent with Cryptococcus neoformans. The patient had a lumbar puncture that was negative for Cryptococcal antigen, and patient was discharged on oral fluconazole. The fungal culture from the BAL was eventually positive for C. neoformans, 2 weeks later.DISCUSSION: Cryptococcal pneumonia of this magnitude is incredibly rare in an immunocompetent patient, especially someone as young as this patient. The patient did not have any exposure nor risk factors, yet required a VATS procedure to confirm the infection. It would be expected with a cryptococcal pneumonia this severe would produce a more systemic response; however, multiple blood cultures and lumbar punctures were negative for any dissemination. The etiology in this case is still unknown, albeit a significant amount of the population has been exposed to Cryptococcus at some point as a child, especially those living in urban areas2. Our patient was fortunate and has responded quite well to fluconazole therapy, and continues to follow up outpatient without complications.CONCLUSIONS: Cryptococcal pneumonia caused by Cryptococcus neoformans is an opportunistic fungal infection, but has the ability to cause severe illness in those immunocompetent. Blood cryptococcal antigen, lumbar puncture, and at times surgical pathology may be required for those with severe illness, and early antifungal therapy may hasten recovery.

INTRODUCTION: Amniotic fluid embolism (AFE) is one of the leading causes of death during pregnancy in developed countries. It is an uncommon, life-threatening complication often associated with advanced maternal age, multi-parity, and placental rupture. It is extremely rare in the first trimester, as the small amount of amniotic fluid and fetal cells are unlikely to breach the maternal circulation. Here, we present an atypical case of AFE occurring at 7 weeks gestation. CASE PRESENTATION:The patient is a healthy 29-year-old nulliparous woman who developed acute onset chest pain, dyspnea, and productive cough with pink frothy sputum within 30 minutes of dilation and curettage (D&C), which she underwent after spontaneous abortion at 7 weeks gestation. Her symptoms were accompanied by acute hypoxemic respiratory failure, shock, and coagulopathy. She did not have any rash or skin changes. Computed tomography angiography of the chest was negative for pulmonary embolism but showed bilateral patchy opacities in all lobes. Transthoracic echocardiogram showed normal biventricular and valvular function. The patient required supportive care with as many as three vasopressors and Bilevel Positive Airway Pressure at 100% FiO2 and left the intensive care unit after approximately 72 hours. She was discharged home after 7 days, by which time she had fully recovered. DISCUSSION: Amniotic fluid embolism is a diagnosis of exclusion, without rapid and accurate diagnostic options available. For this reason, early and atypical cases of AFE are likely underreported. In AFE, the normal physiology is altered due to increased immunological response upon physical breach of amniotic fluid into maternal circulation, releasing procoagulant and vasoactive mediators to cause anaphylactic reaction to the fetal antigen (1). Hence, the imbalance can cause multi-organ failure, exhibited through a classic triad of hypotension, hypoxia, and coagulopathy that were demonstrated in our case without clear etiology for shock and respiratory decompensation. Management is focused on adequate cardiovascular, pulmonary, and hematologic support. Because no cases of recurrence have been reported, current data suggests successful subsequent pregnancies (2). CONCLUSIONS: Our case highlights a patient at 7 weeks gestation with unexplained shock, respiratory failure, and coagulopathy less than 1-hour status post D&C, and may represent the earliest documented case of AFE. Diagnosis of AFE is based upon clinical findings and symptoms, with treatment focused on providing adequate hemodynamic support. Due to limited understanding of its pathophysiology, an emphasis on early diagnosis and treatment is critical to prevent significant mortality.

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