Laryngeal cryptococcosis: Clinical presentation and treatment of a rare cause of hoarseness

Cryptococcosis in the Vocal Cords, Trachea, and Bronchi

Laryngeal and endobronchial cryptococcosis are rare conditions, and to our knowledge, there have been only 23 cases of laryngeal cryptococcosis, and 18 cases of endobronchial cryptococcosis previously reported in the English literature. We herein report an extremely rare case of cryptococcosis with simultaneous laryngeal and endobronchial involvement. This case highlights the importance of paying close attention to possible occurrence of cryptococcosis of the airway tract in patients with asthma treated with high-dose inhaled corticosteroids.

Laryngeal Cryptococcosis: An Evolving Rare Clinical Entity

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.

Laryngeal Cryptococcoma Resulting in Airway Compromise in an Immunocompetent Patient: A Case Report

Cryptococcus neoformans is a yeast than can result in isolated or disseminated infections. This case report describes an immunocompetent patient presenting with airway obstruction secondary to laryngeal crypotococcoma, mimicking a laryngeal malignancy, and describes associated management. A 68-year-old immunocompetent female with a new positron emission tomography-avid laryngeal lesion was intubated after acute respiratory decompensation. Airway evaluation revealed diffuse mucosal changes throughout the endolarynx with significant loss of normal native tissue architecture. Operative biopsy confirmed infection of C neoformans. The patient was treated with extended-course fluconazole. This case reinforces characteristic physical and histologic findings described for laryngeal cryptococcal infection. Laryngoscope, 129:926-929, 2019.

Laryngeal Cryptococcosis Associated With Inhaled Corticosteroid Use: Case Reports and Literature Review

Laryngeal cryptococcosis is a rare clinical entity. There have been a limited number of case reports in the literature with no consensus regarding optimal management. This review contributes two additional case reports of immunocompetent patients with cryptococcal infection of the larynx in whom exposure to high doses of inhaled corticosteroids is proposed as a significant risk factor. Twenty cases were identified from review of the literature. All patients presented with hoarseness and a spectrum of microlaryngoscopic features, often mimicking laryngeal malignancy. The majority of cases were treated with systemic antifungal therapy, three cases had surgical excision alone, and another three had a combination of medical and surgical management. Risk factor modification, in the form of a reduction in inhaled corticosteroid was employed in the two new cases, and in some previously published cases. Risk factor modification, such as reduction of inhaled corticosteroid dose, in addition to oral antifungal agents can be effective in managing cryptococcal laryngitis.

Laryngeal cryptococcosis: Literature review and guidelines for laser ablation of fungal lesions

OBJECTIVES/HYPOTHESIS

To describe the demographics, clinical manifestations, diagnosis, treatment, and outcomes of laryngeal cryptococcosis. Antifungal therapy guidelines are provided and the use of laser ablation is discussed.

DATA SOURCES

PubMed, OVID MEDLINE, and Embase databases and one patient who presented to our institution's otolaryngology department.

REVIEW METHODS

A review of the English-language international medical literature was conducted using the terms ("larynx" or "laryngeal diseases") and ("Cryptococcus" or "cryptococcosis") to identify reported cases of laryngeal cryptococcosis. Databases were searched from inception through January 2015.

RESULTS

Eighteen cases were identified and reviewed, including the first reported case of potassium-titanyl-phosphate laser ablation. All patients presented with hoarseness, and two (11%) presented with acute airway obstruction that required tracheotomy. Six patients (33%) were immunocompromised, including three (17%) who had an underlying human immunodeficiency virus infection. Seven cases (39%) described an exophytic mass. Histopathology indicated pseudoepitheliomatous hyperplasia in seven of the 17 reported results (41%). Methenamine silver stain was used in 12 of the 15 described cases (80%) to identify the fungus. Lumbar puncture results were reported for seven patients, none of whom had meningitis. Antifungal therapy was used in 15 cases (83%), and two (11%) received additional laser ablation treatment. Eleven patients (61%) had complete resolution.

CONCLUSIONS

Laryngeal cryptococcosis is a rare cause of persistent hoarseness. Most patients have complete resolution after treatment. For complex and obstructive cases, laser ablation coupled with antifungal therapy can successfully manage laryngeal cryptococcosis in select patients.

LEVEL OF EVIDENCE

NA Laryngoscope, 126:1625-1629, 2016.

Primary Larynx Cryptococcus neoformans Infection: A Distinctive Clinical Entity

Cryptococcus neoformans can directly infect the vocal cords. Endoscopic findings were undistinctive from most infiltrative diseases. Tissue biopsy was essential for the diagnosis. Inhaled corticosteroids can predispose to the infection, and fluconazole 400 mg daily for at least 6 weeks appeared to be minimal to achieve a permanent cure.

Cryptococcal infection of the larynx: case report

Objective:

Laryngeal cryptococcosis is a rare condition. In this report, we describe the findings for and treatment of a 58-year-old man withCryptococcus gattiiinfection of the right vocal fold.

Method:

Case report and review of the relevant English language literature.

Results:

The patient presented with persistent hoarseness of voice. Laryngoscopy demonstrated an irregular, red lesion on the right vocal fold. Histopathological examination identified cryptococcus. The patient was treated with oral fluconazole 400 mg/day for eight weeks.

Conclusion:

Laryngeal involvement byCryptococcus gattiican result from prolonged inhaled corticosteroid therapy and proximity to eucalyptus trees. The clinical presentation, laryngoscopic findings and imaging results of laryngeal involvement may mimic a neoplasm. Histopathological examination can demonstrate the causative organism. Management consists of advice from an infectious disease specialist together with adequate treatment by antifungal agents.