Pulmonary <i>Aspergillus fumigatus</i> and <i>Cryptococcus neoformans</i> Co-Infection on an Underlying Sarcoidosis Condition: Report of a Rare Case

Sarcoidosis is a systemic granulomatosis from an unknown etiology, particularly affecting the lungs and the lymphatic system. It is associated with an immune deficiency involving an excessive immune response mediated by TH1 lymphocytes. Its evolution can lead to serious complications such as pulmonary fibrosis, pulmonary hypertension, bronchial stenosis and opportunistic infections. Opportunistic infections rarely occur on an underlying sarcoidosis condition. We report a rare case of pulmonary aspergillary and cryptococcal co-infection, on a patient with sarcoidosis who was finally lost to follow up. It was about a 47 years old female patient, diagnosed in 2015 for mediastino-pulmonary and neurological sarcoidosis. She was in therapeutical rupture after a 3-month period of corticotherapy at a dosage of 20 mg daily. The patient has been lost of sight for 3 years and was seen again on November, 22nd, 2018 at the Internal Medicine/Rheumatology Department of DALAL JAMM Hospital. At his admission she presented: a low grade hemoptysia, a chronic cough, a shortness of breath on exertion CRD Stage 2. At the biological investigation, the CRP was at 71.9 mg/l. Calcium serum levels were at 102.6 mg/l. Sputum culture and AFBS were negative. The screening serology of aspergillary Ig G was positive at 12.4 UA/ml. Thoracic High Resonance CT pointed suggests a Stage 2 Sarcoidosis complicated with aspergillary graft. The bronchoscopy showed out a severe suppurated bronchopathy. Microscopic examination of the BAF found some Cryptococcus neoformans settlement. We concluded a diagnosis of pulmonary aspergilloma and cryptococcosis co-infection with an underlying condition of Stage 2 Sarcoidosis. We successfully treated our patient with an oral intake of Itraconazole at a dosage of 400 mg daily over a period of 10 days. This is a rare and life-threatening triple association. In our case, the patient was lost to follow up for a long period and this was considered as the first morbidity risk factor.