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+A 73-year-old man who had been diagnosed with type 2 diabetes mellitus at 35 year of age, who had severe diabetic neuropathy and diabetic-ESRD complained of respiratory distress and sudden chest pain.
+On the first day of treatment, he visited the emergency room.
+A physical examination revealed that his body temperature was 35.4°C, his heart rate was 90 beats/min with a regular rhythm; and his blood pressure was 130/77 mmHg.
+A physical examination revealed coarse crackles on bilateral lung auscultation.
+The laboratory data showed a WBC count of 8,800/μL with a shift to the left (neutrophils 82%), Hb 10.2 g/dL, blood urea nitrogen (BUN) 82.2 mg/dL, creatinine (Cre) 6.50 mg/dL, HbA1c 5.9%, creatine kinase (CK) 189 IU/L, C-reactive protein (CRP) 8.51 mg/dL, brain-type natriuretic peptide (BNP) 127.4 pg/mL.
+A chest radiograph revealed perihilar consolidations and air bronchograms (Fig.1).
+An electrocardiogram revealed ST-segment elevation and poor R-wave progression in leads V1-V3, and echocardiography revealed apical and ventricular asynergy.
+The patient was therefore diagnosed with acute myocardial infarction and congestive heart failure.
+Coronary angiography was performed, revealing severe angiostenosis in the septal branch.
+PCI was therefore performed.
+The patient required continuous maintenance dialysis.
+On the following day, the patient went into cardiorespiratory arrest and cardiopulmonary resuscitation was performed, followed by mechanical ventilation.
+On day 8, ventilator assistance was discontinued.
+However, the patient produced an increasing volume of sputum, which began to appear purulent.
+Pseudomonas aeruginosa was identified from a sputum culture, and tazobactam/piperacillin (TAZ/PIPC) (4.5g q12h) was administered.
+Despite this therapy, the patient's respiratory condition worsened and a chest computed tomography (CT) scan on day 15 revealed bilateral perihilar opacities, pleural effusion, and atelectasis.(Fig.2).
+We suspected the development of complications such as microbial substitution, pneumomycosis and thus performed sputum culturing and serum fungal antigen tests.
+The administration of TAZ/PIPC was changed to meropenem (0.5 g/day).
+On day 16, the patient's serum tested positive for Cryptococcus antigen.
+On day 21, cryptococcal bodies were identified in two sets of blood cultures and liposomal amphotericin B (L-AMB) (3 mg/kg/day) was administered.
+On day 23, cryptococcal bodies were identified in the sputum, cerebrospinal fluid, and bilateral pleural effusion (Fig.3).
+The patient was therefore diagnosed with disseminated cryptococcosis.
+On day 25, brain CT revealed the absence of intracranial hypertension and a brain abscess.
+The patient was not infected with human immunodeficiency virus (HIV).
+The administration of L-AMB (3 mg/kg/day) was continued.
+On day 31, chest CT revealed a solitary nodule in the left lingular segment for the first time, which was suspected to be a pulmonary cryptococcus lesion (Fig.4a).
+After several days, all of the sputum, blood, bilateral pleural effusion, and cerebrospinal fluid cultures tested negative.
+On day 52, chest CT revealed another lung nodule in the right pulmonary apical region.
+These nodules gradually decreased in size until day 79 (Fig.4b and c).
+Although L-AMB was considered effective, the C-reactive protein level remained elevated and the bilateral pleural effusion continuously increased.
+The patient lost consciousness because of decreased vital capacity with increasing bilateral pleural effusion and was diagnosed with CO2 narcosis.
+The patient's general condition deteriorated.
+On day 87, ventricular fibrillation occurred and the patient died.
+Autopsy was not performed.
+At a later date, the Cryptococcus isolate was identified and classified as Cryptococcus neoformans var. grubii (serotype A) by a genetic analysis.