SHM Converge Scientific Abstract ePoster Gallery-Cryptic Tales: A Case of Multi-Organ Immune Checkpoint Inhibitor Toxicity and Cryptococcal Fungemia

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This case describes a 77-year-old man with long-standing lung squamous cell carcinoma who developed severe immune checkpoint inhibitor (ICI) toxicities, including myocarditis, pneumonitis, and hepatitis, requiring prolonged prednisone therapy. While tapering steroids, he experienced recurrent cough, dyspnea, failure to thrive, and worsening lung infiltrates. These symptoms were initially treated as community-acquired pneumonia and possibly ICI-pneumonitis flare, but did not improve.<br /><br />Because of the lack of response, clinicians broadened the workup and discovered disseminated cryptococcal infection. Blood cultures grew Cryptococcus neoformans, chest CT showed progressive nodular and consolidative bilateral lung disease consistent with possible cryptococcal pneumonia, and lumbar puncture revealed elevated opening pressure, elevated protein, and positive cerebrospinal fluid cultures, confirming CNS involvement. On focused history, the patient also reported blurry vision and headaches, suggesting neurologic disease.<br /><br />He was treated with amphotericin B and flucytosine, and prednisone was cautiously reduced while monitoring for return of ICI-related symptoms. Despite therapy, he developed progressive respiratory failure, transitioned to comfort care, and died shortly thereafter.<br /><br />The report highlights that long-term corticosteroid use for ICI toxicity increases the risk of opportunistic infections such as cryptococcosis. Hospitalists should maintain a high index of suspicion when infection symptoms persist despite standard antibiotics, especially in immunosuppressed patients. Recommended evaluation includes thorough history and physical examination, cryptococcal antigen testing, lumbar puncture, chest and brain imaging, fungal cultures, and histopathology. Accurate classification of the syndrome—CNS, disseminated, isolated pulmonary, or direct inoculation—is essential to guide antifungal treatment. Early induction therapy with liposomal amphotericin B plus flucytosine, followed by fluconazole consolidation, is key to reducing fungal burden and relapse risk.

Asset Subtitle

Lauren D. Pomerantz

Meta Tag

Author List Gretchen A. Colbenson, Lauren D. Pomerantz

Category Clinical Vignettes

Concept Cryptococcosis

Concept Cryptococcal Antigen

Concept Liposomal Amphotericin B

Concept Flucytosine

Concept Corticosteroids

Distinguished Non-Finalist

Presenter Organization Mayo Clinic Graduate School of Medical Education

Presenting Author Lauren D. Pomerantz

Track Adult

Keywords

immune checkpoint inhibitor toxicity

cryptococcal infection

Cryptococcus neoformans

lung squamous cell carcinoma

prednisone therapy

disseminated cryptococcosis

cryptococcal pneumonia

central nervous system involvement

amphotericin B

flucytosine

Cryptococcosis

Cryptococcal Antigen

Liposomal Amphotericin B

Flucytosine

Corticosteroids