Pulmonary Cryptococcosis Co-existing with Pulmonary Tuberculosis in a Nigerian HIV-infected Patient: A Case Report

Tuberculosis (TB) and cryptococcosis cause severe morbidity and mortality in HIV-infected individuals in sub-Saharan Africa. However, cryptococcosis and TB co-infection is rare. We present a case of pulmonary cryptococcosis co-existing with pulmonary TB in a 42 year old Nigerian woman who had received Highly Active Antiretroviral Therapy (HAART) for about 6 months with CD4 count of 98 cells/mm3. In the second month of HAART, she developed smear positive TB and was commenced on anti-TB therapy. Following initial improvement, she developed new onset cough, low grade fever, weight loss, breathlessness and chest pain. Repeat sputum Acid Fast Bacilli (AFB) was negative but GeneXpert/MTB/Rif detected Mycobacterium tuberculosis (MTB) with no resistance to Rifampicin. Sputum fungal culture and Indian ink staining confirmed cryptococcosis. The patient was commenced on oral fluconazole therapy; anti-TB and HAART were continued. She subsequently improved but was unfortunately lost to follow-up. Pulmonary cryptococcosis should be considered in the differential diagnosis of severely immunosuppressed HIV-infected patients with chronic respiratory symptoms.