Pôster:

Infections are a major cause of hospitalization and death in immunocompromised patients, representing 3.6% of the causes of death among patients with systemic lupus erythematosus (SLE). Although most are due to bacterial infections, the prevalence of fungal infection is increasing in these populations, one of the most frequent being cryptococcosis.

Case report

A 37-year-old female patient with SLE diagnosed in 2010, at the time with cutaneous and joint manifestations. In 2015 it evolved with nephritis and in 2017 presented myocarditis, in both complications received methylprednisolone and cyclophosphamide. Currently using azathioprine 200 mg, hydroxychloroquine 400 mg and prednisone 5 mg. The dose of azathioprine has recently been increased due to the activity of SLE: high ESR and CRP, worsening of lymphopenia, increased anti-DNA title, decreased complement. A chest X-ray was performed in June 2018 to screen for latent tuberculosis due to the need to optimize immunosuppression after myocarditis. A nodule was identified in the lower third of the right lung measuring 26x25 mm. In the following month, a computed tomography (CT) revealed two solid pulmonary nodules with regular contours in the anterior upper right lobe segments measuring 1.9x2 cm and a nodule in the basal lateral segment of the right lower lobe measuring 1.8x2, 5 cm, and small subpleural opacity in the posterior basal segment. After 4 months, a new CT of the chest that identified cavitations inside the nodule in the right upper lobe. After 4 months, increased cavitation and cavitation appeared in the other nodule. Throughout this period, the patient remained asymptomatic from the respiratory point of view. PPD, BAAR and culture of sputum mycobacteria were also performed, the results of which were negative. Patient was submitted to transbronchial biopsy guided by CT, whose anatomopathological result was compatible with cryptococcosis. Initiated treatment with fluconazole 300 mg.

Conclusion

Autoimmune diseases often require high doses of immunosuppression to control symptoms and reduce organ damage. Due to the immunological defects in SLE patients, this makes them susceptible to opportunistic infections, even if they are not receiving immunosuppressive treatment. Pulmonary cryptococcosis is characterized by dyspnea, fever, dry cough, nocturnal sweating and progressive respiratory deterioration, occasionally fulminating. The most common radiological pattern is multiple nodular involvement, the presence of cavitation is exceptional. It is important to note in this case that cryptococcosis can manifest asymptomatically and with an atypical radiological pattern, and an attenuated and suspected diagnosis in immunocompromised patients is indicated.