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Chest Infections |

Lung Mass and Headache in a 51-Year-Old Immunocompetent Patient

Mohammed Moizuddin, MD; Mohammed Nayeem, MD; Muhammed Imtiaz, MD; Ria Gripaldo, MD
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University of South Carolina School of Medicine, Columbia, SC


Chest. 2014;146(4_MeetingAbstracts):136A. doi:10.1378/chest.1994935
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Abstract

SESSION TITLE: Infectious Disease Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: A high index of suspicion is critical for diagnosis of pulmonary cryptococcal infection in immunocompetent patients. Occasionally, just a radiological demonstration of a non-specific peripheral pulmonary opacity may draw attention to the disease. We report a rare case of 51-year old non-HIV female who presented with headaches and pulmonary mass and was diagnosed with disseminated cryptococcal infection.

CASE PRESENTATION: 51 year old female history of tobacco abuse presented to our office with headaches and non-productive cough of three weeks duration. Physical exam revealed bilateral papilledema. Magnetic Resonance Imaging (MRI) of brain demonstrated extensive abnormal leptomeningeal gadolinium enhancement. Computed tomography (CT) of the chest with contrast demonstrated mass in the left lower lobe. Transbronchial lung biopsy (TBLB) revealed cluster of pleomorphic yeast forms admixed with foamy macrophages. Cerebrospinal fluid analysis (CSF) revealed a positive India ink smear, cryptococcal antigen and cultures grew cryptococcus gatti. A complete immunological and infective work-up was negative. She was succesfully treated with Flucytocine and Amphotericin.

DISCUSSION: Pulmonary cryptoccocal infections can present as asymptomatic nodule or locally invasive parenchymal, pleural, or disseminated infection. Diagnosis is clinically challenging given general symptoms. Diagnostic criteria include demonstration of organism in histopathological specimen or positive tissue cultures as well as positive antigen with clinical and radiological evidence of disease. Central nervous system infection can present as typical meningitis or less typical headaches, seizures, and confusion. Demonstration of cryptococcal organism in CSF fluid is usually diagnostic. Treatment for asymptomatic pulmonary disease is controversial in healthy hosts. In non-HIV patients with mild to moderate symptoms, treatment with antifungals (Fluconazole & Amphotericin) for 6-12 months has been noted to be beneficial.

CONCLUSIONS: Radiological presence of non-enhanced low-attenuation areas of consolidation or mass with peripheral, lower lobe predominance and lack of tree-in bud appearance on CT in a patient with meningitis should raise the suspicion of pulmonary Cryptococcus. A high index of suspicion, early diagnosis, and prompt treatment with antifungal drugs is essential and maintenance treatment is needed to prevent relapse

Reference #1: Marina Nunez MD etal., Pulmonary Cryptococcosis in the immunocompetent host. CHEST/118/2/August, 2000

DISCLOSURE: The following authors have nothing to disclose: Mohammed Moizuddin, Mohammed Nayeem, Muhammed Imtiaz, Ria Gripaldo

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