Cryptococcal infections pose a clinical challenge in immunocompromised patients. Following the central nervous system, the respiratory system is most commonly affected. Pulmonary involvement includes localized nodular lesions with or without cavitation, segmental pneumonic infiltrates, patchy interstitial or alveolar infiltrates, pleural effusions, hilar masses, and thoracic lymphadenopathy. Clinical symptoms are cough, dyspnea, fever, night sweats, weight loss, and hemoptysis. Herein we describe our experience with an unusual case of endobronchial cryptococcosis.
A 72-year-old man was hospitalized following a syncopal episode related to sustained ventricular tachycardia. Coronary angiography disclosed global myocardial dysfunction, an ejection fraction of 20%, and normal coronary arteries. Myocardial biopsy revealed giant cell myocarditis. He was treated with intravenous methylprednisolone cyclosporine and azathioprine. One week after admission workup of sudden onset dyspnea revealed the diagnosis of pulmonary embolism and therapeutic anticoagulation was initiated. Four weeks into immunosuppressive therapy repeat myocardial biopsy and echocardiography showed improvement of his giant cell myocarditis. Five weeks after admission pulmonary consultation was requested to evaluate fever, worsening dyspnea, wheezing, and moderate hemoptysis. Past medical history included adult onset asthma, chronic lymphocytic leukemia, celiac disease, asbestos related pleural disease and hypothyroidism. Physical examination showed only mildly decreased breath sounds and basilar crackles bilaterally. His immunosuppressive regimen at this time included oral cyclosporine and prednisone, 5 mg per day. Other medications were warfarin, trimethoprim/sulfamethoxazole, ipratropium, albuterol, fluticasone/salmeterol, lisinopril, levothyroxine, and lansoprazole. Laboratory tests showed: hemoglobin of 10.5 g/dl, WBC 41.000/microl, platelet count 134.000/microl, INR 2.6, PTT 32 s and creatinine 1.7 mg/dl. Blood cultures were negative and chest CT revealed mild nodularity around the major fissures but was otherwise unchanged. Bronchoscopy to investigate for the cause of hemoptysis and infectious pathogens disclosed extensive pseudomembranes covering the posterior wall of the distal trachea extending into the left and right mainstem bronchi to the takeoff of the upper lobe bronchi bilaterally. Upon removal friable, nodular mucosa with shallow ulcerations was revealed Figure 1. Endobronchial biopsy and bronchoalveolar lavage showed benign bronchial tissue with fungal organisms consistent with cryptococcus. Figure 1 Cultures of lavage fluid grew Cryptococcus neoformans. The diagnosis of endobronchial cryptococcosis was established. Serum cryptococcal antigen was elevated with a titer of 1:4. Cerebrospinal fluid examination including cryptococcal antigen was negative. Liposomal amphotericin was initiated but was changed to fluconazole, 400 mg per day because of drug intolerance. Antifungal therapy was continued at this dose for 3 months followed by longterm maintenance therapy with Fluconazole 200 mg per day.
Endobronchial involvement is a rare manifestation of pulmonary cryptococcosis. It can occur in immunocompromised and immunocompetent individuals. In addition to our patient 7 cases have been reported in the literature. Clinical symptoms are frequently suggestive of airway disease. Radiographic findings commonly show postobstructive atelectasis but are usually non-specific. Bronchoscopic evaluation frequently shows endobronchial masses but endobronchial involvement can also manifest as pseudomembranous tracheobronchitis similar to that described in association with aspergillus infection. Considering the high prevalence of documented CNS involvement in patients with endobronchial cryptococcosis  their evaluation should include a lumbar puncture.
Endobronchial cryptococcosis needs to be considered in the differential diagnosis of immunocompromised patients with airway related symptoms or hemoptysis. Bronchoscopy is a valuable tool to detect endobronchial disease and establish the diagnosis. Because of the low incidence of endobronchial cryptococcosis, no prospective data is available to guide management. Most authors suggest aggressive therapy with either amphotericin B or fluconazole. .
T. Peikert, None.