JCPSLP Vol 22 No 2 2020

Learning from our clients

Cryptococcal laryngitis A case report of rare clinical manifestations of dysphagia and dysphonia Rebecca Sexton, Sarah Fulton, and Bena Brown

Cryptococcal laryngitis is a rare infection, with only 30 reported cases - worldwide. There is an emerging consensus in the literature that cryptococcal laryngitis should be considered as a differential diagnosis in patients presenting with persistent vocal hoarseness. The role of the speech-language pathologist (SLP) in differential diagnosis, and the assessment and management of voice and swallowing sequelae as a result of cryptococcal laryngitis, is currently unknown. This paper reports on the presentation of an 82-year-old gentleman with a case of severe cryptococcal laryngitis and the preliminary swallow assessment and vocal perceptual analysis undertaken as part of his clinical care. This case is the 31st reported case of this infection worldwide. This paper aims to raise awareness among clinicians of this rare condition, its clinical manifestation, and the speech-language pathologists’ role in the differential diagnosis and management of swallowing and voice sequelae for this patient population. W ithin the practice of speech-language pathology, persistent vocal hoarseness is a common patient presentation, potentially arising from a variety of aetiologies. Speech-language pathologists are commonly involved in patient care when medical management has been unsuccessful in reducing voice symptoms and/or to manage the functional consequences of voice disorders (Cohen, Dinan, Kim & Roy, 2016). Where the presenting voice condition limits a patient’s participation in activities of daily living, particularly in the case of unknown aetiology, it is vital the speech pathologist advocates for further investigation. Speech-language pathologists can contribute specialised clinical information as part of the diagnostic team when persistent hoarseness manifests as a presenting symptom. Persistent hoarseness is often diagnosed as a symptom of laryngitis, an inflammation of the larynx, and can be classified as acute or chronic. Acute laryngitis often resolves without requiring medical intervention; however, those with

chronic laryngitis often present for further investigation by medical experts such as ear, nose and throat (ENT) specialists (Stein & Noordzij, 2013). Chronic laryngitis can be attributed to laryngopharyngeal reflux, poor laryngeal/ vocal misuse behaviours, cancer of the head and neck, and bacterial and/or fungal infections (Stein & Noordzij, 2013). Literature suggests that for immunocompetent patients presenting with vocal cord dysfunction, fungal laryngitis is often underestimated and other presentations such as laryngopharyngeal reflux may be overrepresented in differential diagnosis (Issa & Thomas, 2018). Multiple fungal infections of the larynx have been identified in the literature and include candidiasis, blastomycosis, coccidioidomycosis, paracoccidioidomycosis, aspergillosis and sporotrichosis (Klein, Tiu & Lafreniere 2005). One particularly rare cause of chronic laryngitis is cryptococcal laryngitis. The cryptococcus neoformans fungal infection commonly presents as a respiratory infection or meningitis and has been associated with pigeon exposure (Delgado, Taguchi, Mikami, Myiajy, Villares, & Moretti, 2005; Levitz, 1991). Cryptococcus neoformans presenting in the larynx is uncommon (Bamba. Tatemoto, Inoue, Uno, & Hisa, 2005; Browning, Schwartz & Jurado, 1992). As a result of the non-specific clinical findings, and the investigation of multiple differential diagnoses for laryngitis, there has been a reported delay in the provision of appropriate treatment for those patients with cryptococcal laryngitis (Bergeron, Gagne, Cote, Chenevert, Dube, & Pelletier, 2015). Patients with suppressed immune systems, particularly those with HIV, are more susceptible to a cryptococcal infection (Bergeron et al., 2015; Gordon, Stor, Yapa, Bova, & Marriott, 2010). Once diagnosed however, patients commonly respond to a course of anti-fungal therapy. Although there is a consensus that cryptococcal laryngitis should be considered as part of the differential diagnosis in a patient presenting with persistent hoarseness and/or recurrent laryngitis, due to its rarity there is often a delay in diagnosis (Worrall, Lerner, Naunheim, & Woo, 2019). As such, evidence of the involvement of speech-language pathologists in the assessment and management of the swallowing and voice sequelae of cryptococcal laryngitis is non-existent in the literature. In previously reported case series (n = 30), 100% presented with persistent hoarseness (Quintero, Trachuk, Lerner, Sarunbam, Pirofski, & Park, 2019; Worrall et al., 2019). Of the reported cases, 50% were male and there was a median age of 63 years (Quintero et al., 2019; Worrall et al., 2019). One case was referred to a speech-

KEYWORDS ANTI-FUNGAL THERAPY CRYPTOCOCCAL DYSPHAGIA DYSPHONIA LARYNGITIS VOCAL HOARSENESS THIS ARTICLE HAS BEEN PEER- REVIEWED

Rebecca Sexton (top), Sarah Fulton (centre) and Bena Brown

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JCPSLP Volume 22, Number 2 2020

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