Chest Infections |

An Unusual Case of Cryptococcal Pneumonia in an Immunocompetent Patient FREE TO VIEW

Sara Ahmed, MD; Jared Radbel, MD; Dany Elsayegh, MD; Ayesha Ahmed, MBBS; Farshid Daneshvar, MD; Gita Vatandoust, MD; Ambreen Khalil, MD
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Staten Island University Hospital, Staten Island, NY

Chest. 2013;144(4_MeetingAbstracts):178A. doi:10.1378/chest.1688108
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SESSION TITLE: Infectious Disease Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Cryptococcosis is an invasive mycosis that occurs worldwide. While immunocompromised patients are at increased risk for severe or disseminated pulmonary infection, it is rare to occur in an immunocompetent host.

CASE PRESENTATION: We present a 45-year-old woman with chronic progressive cough associated with malaise and lower extremity arthralgia. Review of systems and physical examination were significant for 10-lb weight loss, subjective fevers, painful pretibial erythema, and bilateral knee synovitis. During the hospitalization she had no resolution of symptoms despite empiric treatment for bacterial pneumonia. Computed tomography of the chest revealed multiple cavitary lesions in the right upper and left lower lobes. The results of HIV testing and quantiferon gold assay were negative. Bronchoscopy with bronchoalveolar lavage was non-diagnostic. Serum cryptococcal antigen was positive at a titer of 1:256. A diagnosis of cryptococcal pneumonia with associated erythema nodosum was made. A lumbar puncture revealed no evidence of CNS involvement. Treatment with fluconazole 400 mg per day was started and resulted in improvement of the patient’s symptoms.

DISCUSSION: The diagnosis of pulmonary cryptococcal infection is made through sputum culture, bronchoalveolar lavage, typical radiographic findings, and serum cryptococcal antigen (sCRAG). Immunocompromised patients are more likely to have a larger extent of pulmonary involvement or cavitation on radiological examination [1]. A positive sCRAG may reflect concomitant extra-pulmonary disease. Interestingly, our patient displayed multiple cavitary lesions and had a significant elevation in sCRAG titers with out CNS symptoms. Examination of the CSF for dissemination in immunocompetent hosts may be avoided if there is asymptomatic pulmonary involvement, lack of CNS symptoms, and a negative or very low serum cryptococcal antigen [2]. Currently, the use of fluconazole 400 mg daily for 6-12 months is advised for mild-moderate symptoms, while severe disease warrants a more potent protocol [2]. Our patient was started on treatment with fluconazole and is continuing to have clinical and radiological improvement.

CONCLUSIONS: We present a rare case of cryptococcal pneumonia producing extensive cavitation with a significant elevation of sCRAG despite immunocompetency. Our negative CSF result supports the concept of limiting lumbar punctures to patients who are immunocompromised.

Reference #1: Chang WC, Tzao C, Hsu HH, et al. Pulmonary cryptococcosis: comparison of clinical and radiographic characteristics on immunocompetent and immunocompromised patients. Chest. 2006;129(2):333-40.

Reference #2: Perfect JR, Dismukes WE, Dromer F, et al. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the Infectious Diseases Society of America. CID. 2010;50:291-322.

DISCLOSURE: The following authors have nothing to disclose: Sara Ahmed, Jared Radbel, Dany Elsayegh, Ayesha Ahmed, Farshid Daneshvar, Gita Vatandoust, Ambreen Khalil

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