Cryptococcal Meningoencephalitis During Convalescence From Severe COVID-19 Pneumonia

Abstract

Invasive cryptococcal infection in a previously immunocompetent patient complicating coronavirus disease 2019 (COVID-19) pneumonia has not been described before. In this report, a 76-year-old woman survived a bout of respiratory failure from severe COVID-19 pneumonia, during which she received remdesivir, convalescent plasma, corticosteroids, and tocilizumab. Soon after discharge, she developed acute encephalopathy and multifocal ischemic strokes. CSF and blood cultures were positive for Cryptococcus neoformans. Cryptococcal meningoencephalitis should be considered in the differential diagnosis of encephalopathy in a patient with COVID-19. Treatment with high-dose steroids and tocilizumab may be predisposing factors.

COVID-19-associated opportunistic infections: a snapshot on the current reports

“…Likewise, disseminated cryptococcosis [190], meningitis [191], invasive aspergillosis [192], CMV pneumonitis [193], and tuberculosis [194] were reported in patients who received tocilizumab (Table 2). In COVID-19 patients, different cases with cryptococcosis [24,65,[71][72][73], aspergillosis [88], strongyloidiasis [175], PCP [88], CMV [135], and HSV [143] infections were reported following tocilizumab use (Table 3). Inhibition of the JAKs pathway (ruxolitinib [195][196][197], baricitinib [198,199], and tofacitinib [200]), TNFα (infliximab [201,202]), IL-1 (Anakinra [203,204] and Canakinumab [205,206]), and GM-CSF (Mavrilimumab [207]) was also used for mitigating the CSS in COVID-19 patients (Table 1).…”

“…However, it seems that future studies are needed for standard diagnosis and new treatment options of these infections in COVID-19 patients (Table 4). [31,88] Candidiasis [43] Mucormycosis [60] Cryptococcosis [24,65,[71][72][73] Pneumocystis jiroveci (carinii) pneumonia [76,81,88,89] Histoplasma capsulatum [95,96,98] Coccidioides immitis [101,102] Strongyloidiasis [175,176] CMV [130,132,135,136] HSV [143] IL-6 blocker (Tocilizumab)…”

“…Cryptococcosis [24,65,[71][72][73] Pneumocystis jiroveci (carinii) pneumonia [88] Aspergillosis [88] Strongyloidiasis: [175] CMV: [135] HSV: [143] Limitations of the study…”

“…Meningoencephalitis due to C. neoformans was reported in a 73-year-old woman who received azithromycin and dexamethasone after COVID-19 infection [70]. Other cases were reported from COVID-19 patients with several underlying diseases who received immunosuppressive therapy (e.g., corticosteroids and tocilizumab) [24,[71][72][73]. Like other fungal infections, early detection and treatment can improve the outcome of infection in COVID-19 patients.…”

Cytomegalovirus meningoencephalitis in a case of severe COVID-19 Pneumonia. A case report

“…Many cases, studies and reviews specifically reported about meningoencephalitis in cases of COVID-19 [4] , [5] , [6] . The use of steroids and other immune modulatory therapies in the treatment of severe COVID-19 pneumonia predisposes these patients to the re-emergence of opportunistic infections [7] , [8] , [9] . Cytomegalo virus (CMV) reactivation is one of them [10] , [11] .…”