Laryngeal Cryptococcosis: An Evolving Rare Clinical Entity

Abstract

Objectives: Describe the demographics and clinical manifestations of laryngeal cryptococcosis. Develop a simple approach to the diagnostic workup and treatment of localized laryngeal cryptococcal infection. Methods: A new case of laryngeal cryptococcosis encountered at our institution is presented and placed in context of the literature surrounding prior reported cases. PubMed, Google Scholar, SCOPUS, and Web of Science were queried from inception to August 2018 with the terms Larynx or Laryngeal and Cryptococcosis or Cryptococcus by two independent reviewers for English-language cases of cryptococcal infection of the larynx. Results: Twenty-nine unique cases of laryngeal cryptococcosis were identified. Median age at presentation was 65 years old. All patients presented with persistent or progressive hoarseness. Lesions were predominantly on the true vocal cords (79%), 38% associated with an adherent white exudate or leukoplakia. A minority (28%) was immunocompromised, and of the remaining immunocompetent hosts, 67% were found to be using nebulized or inhaled corticosteroids (ICS) prior to infection. Diagnosis should be suspected in patients with chronic laryngitis or mass lesions with the aforementioned risk factors. Diagnosis was made by histopathology with cryptococcal yeasts identified on methenamine silver (55%) and/or mucicarmine stains (48%). Serum cryptococcal antigen testing was unreliable (sensitivity = 39%). The mainstay of effective treatment was prolonged oral Fluconazole therapy, with two cases of laser therapy ablation of residual lesions. Improvement in voice and vocal lesions varied from weeks to months. Conclusions: Laryngeal cryptococcosis is a rare cause of persistent hoarseness, which appears to be clinically evolving and more frequently affecting immunocompetent hosts chronically using nebulized or inhaled corticosteroids. Laryngeal cryptococcal infection is readily treatable with prolonged oral antifungals once biopsy and histopathological stains confirm the diagnosis.

Cryptococcal Anterior Glottic Web from Disseminated Infection Presenting as Confusion: A Case Report

“…The aforementioned study found that prolonged oral Fluconazole was an effective treatment. 3 This was also an important component of the treatment regimen for our patient. Management of anterior glottic webs depends on the thickness and extent of the web.…”

“…Typically, laryngeal manifestations of Cryptococcus include leukoplakia, which has been reported to involve the true vocal cords in 79% of cases. 3 Recently, a study identified 29 cases of laryngeal cryptococcosis, 38% associated with an adherent white exudate or leukoplakia. Although leukoplakia may lead to a degree of glottic stenosis, literature regarding Cryptococcal glottic webs specifically, is lacking.…”

Invasive multifocal cryptococcal airway disease in a teenager with hypogammaglobulinaemia

“…Cryptococcal disease involving the larynx has been reported infrequently in adult patients, but to our knowledge there are no previous reported cases of laryngeal cryptococcosis in children. (4) Pathogenic cryptococci have characteristic virulence factors that contribute to infections, most notably polysaccharide capsules which facilitate immune system evasion. In vitro studies demonstrate the requirement of antibody or complement mediated opsonisation of the capsule for successful phagocytosis and destruction of cryptococci.…”

Invasive multifocal cryptococcal airway disease in a teenager with hypogammaglobulinemia

“…All previous cases were managed with either surgical debridement, systemic antifungals, or both. 3,4 Pathogenic cryptococci have characteristic virulence factors, most notably polysaccharide capsules which facilitate immune evasion. In vitro studies demonstrate the requirement of antibody or complement-mediated opsonization of the capsule for successful phagocytosis and destruction of cryptococci.…”

“…Endoscopic findings include laryngeal edema, erythematous mucosa, leukoplakia, exudate, and distinct lesions. These lesions have had various descriptions including “warty,” “verrucous,” “budding,” or “friable.” All previous cases were managed with either surgical debridement, systemic antifungals, or both 3,4 …”