INTRODUCTION: Pulmonary cryptococcosis has variable clinical and radiographic manifestations, but endobronchial cryptococcosis has rarely been reported. We describe an immunocompetent gentleman who presented with new onset of cough, dyspnea and wheezing, who had fungating and polypoid endobronchial lesions caused by Cryptococcus neoformans.
CASE PRESENTATION: A 74-year-old man presented to the Emergency Center with a 3-week history of dyspnea, productive cough and wheezing. He had recently received antibiotics for “bronchitis”, but continued to be symptomatic. A chest radiograph revealed right hilar prominence and right lower lobe linear opacities. The patient was a retired construction worker, and as a hobby bred chickens in his backyard. He had a 100 pack-year history of cigarette smoking and a history of peptic ulcer disease, but no other serious illnesses. Physical examination revealed normal vital signs and oxygen saturation, wheezes in the right upper lung field and right basilar crackles. The remainder of his examination, including neurological examination, was normal. Serum chemistries, complete blood count and urine analysis were normal. Computerized tomography (CT) scan of the chest demonstrated a right hilar mass with extension into the right upper lobe and bronchus intermedius, and was considered suspicious for malignancy. Additionally, there were focal areas of consolidation in the right lower lobe with air bronchograms suggestive of a post-obstructive pneumonia. Fiberoptic bronchoscopy revealed a polypoid mass in the right upper lobe orifice and a fungating mass occluding 90% of the proximal bronchus intermedius. Endobronchial forceps biopsy showed multiple encapsulated organisms consistent with cryptococcus. Cultures from the bronchoscopy grew Cryptococcus neoformans. Serum cryptococcal antigen was positive with a titer of 1:528, and a human immunodeficiency virus (HIV) antibody test was negative. Lumbar puncture was considered, secondary to the high antigen titer, but the patient refused the procedure. The patient received treatment with oral fluconazole 400 milligrams daily for eight weeks. Repeat CT scan revealed slight shrinkage of the hilar mass, but persistent extension of the mass into the bronchus intermedius. Continuation of oral fluconazole for at least 4 more months was recommended, but the patient felt that his symptoms had resolved and declined further treatment or follow up studies.
DISCUSSIONS: Pulmonary cryptococcosis, usually caused by inhalation of the spore form of this ubiquitous microorganism, is commonly acquired from the soil or bird droppings. We believe that prolonged, heavy exposure to infected chicken droppings caused this patient's infection. Pulmonary cryptococcosis has variable clinical and radiographic manifestations, and most commonly presents as solitary or multiple pulmonary nodules that are often peripherally located.(1) Endobronchial lesions from cryptococcal infection are rare. In a comprehensive search of the medical literature, only 11 cases of endobronchial cryptococcosis have been reported. The majority of these lesions appeared as white lobulated masses and white or red plaques, with one case of a pseudomembranous tracheobronchitis.(2) Furthermore, only 5 of these patients were immunocompetent. The usual treatment is 3 to 12 months of antifungal therapy and has variable rates of success.(1) Given our patient's extensive smoking history, a hilar mass with endobronchial extension was highly suggestive of bronchogenic carcinoma. Polypoid or fungating endobronchial lesions have also been described in metastatic cancers, carcinoid, actinomycosis, Kaposi's sarcoma, primary pulmonary leiomyosarcoma, and norcardiosis.
CONCLUSION: Pulmonary cryptococcosis is being recognized with increased frequency in immunocompetent individuals. Evaluation of a patient's history of exposure to bird droppings may help suggest the possibility of cryptococcal infection. To our knowledge, this is the first reported case of polypoid and fungating endobronchial masses due to Cryptococcus neoformans. Pulmonary cryptococcosis should, therefore, be included in the differential diagnosis of polypoid or fungating endobronchial lesions.
DISCLOSURE: Nisha Rathi, None.