Chest Infections |

A 26-Year-Old Man With Multiple Pulmonary Masses FREE TO VIEW

Christopher Yee*, MD; Dong Chang, MD
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Harbor-UCLA Medical Center, Torrance, CA

Chest. 2012;142(4_MeetingAbstracts):238A. doi:10.1378/chest.1389276
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SESSION TYPE: Infectious Disease Student/Resident Case Report Posters I

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Cryptococcosis primarily causes meningoencephalitis or pneumonia in immunocompromised patients. In the absence of impaired immunity, clinical disease is rare. The following report describes a case of pulmonary cryptococcosis presenting as multiple pulmonary masses in an otherwise healthy adult male.

CASE PRESENTATION: A 26 year-old man with no medical history presented with cough, fevers, shortness of breath, and chest discomfort for 10 days. Prior to admission, he was treated for community-acquired pneumonia at another hospital but failed to improve. The patient denied sick contacts or unusual environmental exposures. The patient's vital signs and cardiopulmonary examination were normal. However, his chest radiograph showed multiple bilateral lung opacities. A chest CT confirmed large pulmonary masses, some with cavitation, in multiple lung fields. The largest lesion measured 7.9 x 4.9 x 4.4 cm. A rapid HIV antibody test, respiratory cultures, and AFB smears of the sputum were negative. The patient had a diagnostic bronchoscopy, but the transbronchial biopsies and bronchoalveolar lavage were non-diagnostic. He then underwent a CT-guided biopsy of one of the lung lesions, which revealed encapsulated organisms consistent with Cryptococcus. The serum cryptococcal antigen titer was 1:512. Blood cultures and a lumbar puncture were negative for disseminated cryptococcosis. The patient was started on oral fluconazole for cryptococcal pneumonia.

DISCUSSION: Pulmonary cryptococcosis in immunocompetent patients is uncommon, and its presentation differs from that in immunocompromised patients. Immunocompetent patients are less likely to exhibit typical symptoms of infectious pneumonia. Radiographically, they are more likely to demonstrate discrete pulmonary nodules, masses, and infiltrates. Given the nonspecific findings on presentation, the diagnosis of pulmonary cryptococcosis is often made by bronchoscopy or surgical lung biopsy. Immunocompetent patients with isolated pulmonary cryptococcosis have a good prognosis and frequently improve with or without antifungal therapy. Their risk of disease progression and systemic dissemination is low.

CONCLUSIONS: While cryptococcosis is most commonly an opportunistic infection in immunocompromised patients, this case highlights the need to also include it in the differential diagnosis for non-resolving pneumonias in immunocompetent patients.

1) Chang WC, Tzao C, Hsu HH, Lee SC, Huang KL, Tung HJ, Chen CY. Pulmonary cryptococcosis: comparison of clinical and radiographic characteristics in immunocompetent and immunocompromised patients. Chest. 2006;129;333-340.

2) Nadrous HF, Antonios VS, Terrell CL, Ryu JH. Pulmonary cryptococcosis in nonimmunocompromised patients. Chest. 2003;124;2143-7.

DISCLOSURE: The following authors have nothing to disclose: Christopher Yee, Dong Chang

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Harbor-UCLA Medical Center, Torrance, CA




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