A 56-year-old woman from New York City comes to the emergency department on Christmas Eve because of a 10-day history of malaise and a progressively worsening headache with occasional nausea and vomiting. She also has had a 6-week history of dyspnea, a productive cough, and night sweats. The patient is accompanied by a 10-year-old boy who says that they initially met while he was walking alone in Central Park and that he found her "covered with pigeons." The patient does not remember her medical history and denies having traveled anywhere recently. She does not smoke cigarettes or use illicit drugs. Her temperature is 38.1°C (100.6°F) and respirations are 25/min. She is alert and fully oriented. Neurologic examination shows no focal findings. There is nuchal rigidity. Her CD4+ T-lymphocyte count is 80/mm3. An HIV screening test is positive. An MRI of the brain shows no abnormalities. India ink staining of cerebrospinal fluid demonstrates spherical yeast forms with thick capsules. Which of the following is the most likely site of primary infection in this patient?

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Quizplus · Accepted Answer

Eductional Objective: Cryptococcus neoformans is a yeast with a thick polysaccharide capsule that is found primarily in soil contaminated by bird droppings.  Inhalation of the pathogen into the lungs leads to asymptomatic primary infection usually followed by life-long latent infection.  However, immunocompromised (eg, advanced AIDS) patients are at high risk for reactivation with spread to the CNS.

A 56-Year-Old Woman from New York City Comes to the Emergency