PRIMARY LARYNGEAL CRYPTOCOCCOSIS ASSOCIATED WITH PROLONGED INHALED STEROID USE. A CASE REPORT

Abstract

Intro: Primary Laryngeal Cryptococcosis is a rare clinical entity. Prolonged use of inhaled corticosteroids has been reported in literature as a significant risk factor in the pathogenesis of the disease. Cryptococcal infections are more commonly seen in immunocompromised hosts with conditions like HIV but can also be seen in otherwise healthy individuals. We report here a case of biopsy proven case of isolated laryngeal cryptococcosis without pulmonary involvement in an immunocompetent elderly male. Methods: Data for the case report was collected by retrospective medical chart review of the patients records. Patient was also followed prospectively for a year as outpatient to assess for outcome. Consent was taken for submission from the patient Findings: Our patient had a history of Asthma with prolonged use of inhaled corticosteroids (>15 years). Presented with progressively increasing hoarseness of voice for 5 months. Gross examination of oropharynx was normal. Fibreoptic laryngoscopy (FOL) showed bilateral irregular thickened, swollen vocal cords and granulation tissue. Histopathology showed benign mucosa covered with tissue exhibiting surface ulceration with moderate to severe acute and chronic granulomatous inflammation and granulomas showing collection of epitheloid cells with scattered foreign body giant cells. Rounded narrow based budding yeast with thick capsule were evident on PASD stain suggestive of Cryptococcus sp. Serum Cryptococcal Antigen titers were also raised (1: 4). Patient was managed medically with oral Fluconazole (400mg OD) and reduction in dose of ICS for 6 months duration with resolution of symptoms and improvement in titers. Conclusion: A total of 25 cases of cryptococcal laryngitis have been reported in literature so far. Sensitivity of serum Cryptococcal antigen remained low (39%). Majority (>60%) patient had exposure to high-dose inhaled steroids. Anti-fungal therapy (Fluconazole) was instituted in most cases with good outcomes. Reduction in dose of inhaled steroids for risk factor modification has shown to be effective in treatment of Cryptococcal Laryngitis