Abstract
An 82-year-old supplemental oxygen dependent woman with severe COPD presented with an eight month history of worsening hoarseness and stridor. Office laryngoscopy revealed laryngeal edema and ulcerative masses throughout the larynx. In-office biopsies were positive for Cryptococcus neoformans . This report details a novel approach to the treatment of cryptococcal laryngitis, a combination of in-office pulsed-dye laser (PDL) ablation and medical therapy. Despite treatment with oral fluconazole, the recommended treatment for cryptococcal laryngitis the patient continued to be symptomatic with dysphonia and throat discomfort. Repeated laryngeal exam demonstrated persistent cryptococcal nodules. The patient was subsequently effectively treated with an in-office PDL laser. This case demonstrates the efficacy of in-office laser treatment for residual laryngeal Cryptococcus. For patients like this one, who have failed medical therapy and are unfit for general anesthetic, the in-office laser provides an excellent alternative treatment approach.
1
Introduction
Cryptococcus neoformans is a microorganism found in pigeon feces, fruit and vegetables. Transmitted via inhalation, C. neoformans commonly affects the lungs, resulting primarily in pulmonary infections in immunocompromised individuals. It can later disseminate to the CNS, meninges and bone . Patients infected with C. neoformans are typically assessed for HIV and other systemic immunosuppression disorders . C. neoformans of any location apart from the larynx is rare. Edema and erythema, and multiple white, raised lesions involving the vocal folds are features commonly visualized by indirect laryngoscopy of cryptococcal laryngitis. What varies among previously reported cases, however, are the treatment regimens for the management of this rare disease presentation. While some cases required no treatment and spontaneously resolved, others were placed on antifungals such as fluconazole and even amphotericin. This report details the treatment of cyroptococcal laryngitis with a combination of in-office laser ablation in addition to medical therapy medical therapy – identifying in-office pulsed dye laser (PDL) therapy as a reasonable treatment for this condition.
2
Materials and methods
2.1
Initial case presentation
An 82-year-old woman with a history of coronary artery disease and severe chronic obstructive pulmonary disease (COPD) presented with eight months of worsening hoarseness and mildly audible stridor. She had a 25 pack-year history of smoking but had quit over 20 years prior to presentation. She required emental oxygen and inhaled steroids for her COPD. She denied otalgia, dysphagia, odynophagia, weight loss, or shortness of breath. Office transnasal flexible laryngoscopy revealed laryngeal edema and diffuse ulcerative masses on bilateral false and true vocal folds ( Fig. 1 ). Additionally, granulomas were seen in the posterior commissure. The voice was rough, breathy and strained. In-office biopsies of her lesions were performed ( Figs. 2–3 ). These were positive for fungal, crypotcoccal laryngitis.
2
Materials and methods
2.1
Initial case presentation
An 82-year-old woman with a history of coronary artery disease and severe chronic obstructive pulmonary disease (COPD) presented with eight months of worsening hoarseness and mildly audible stridor. She had a 25 pack-year history of smoking but had quit over 20 years prior to presentation. She required emental oxygen and inhaled steroids for her COPD. She denied otalgia, dysphagia, odynophagia, weight loss, or shortness of breath. Office transnasal flexible laryngoscopy revealed laryngeal edema and diffuse ulcerative masses on bilateral false and true vocal folds ( Fig. 1 ). Additionally, granulomas were seen in the posterior commissure. The voice was rough, breathy and strained. In-office biopsies of her lesions were performed ( Figs. 2–3 ). These were positive for fungal, crypotcoccal laryngitis.
