SESSION TITLE: Chest Infections Case Report Posters
SESSION TYPE: Affiliate Case Report Poster
PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM
INTRODUCTION: We present an intriguing case of a pleural effusion due to Cryptococcus neoformans presenting as a transudate
CASE PRESENTATION: 79 year old male with a past medical history significant for end stage renal disease on hemodialysis and ischemic cardiomyopathy with an ejection fraction of 35%, was admitted to the medicine service with a 2 week history of worsening fatigue and shortness of breath. A chest radiograph showed a new large right sided pleural effusion. A therapeutic thoracentesis was performed with removal of 1200 ml of serous fluid which is transudative by Lights criteria. Specifically, the pleural fluid lactate dehydrogenase was 120 IU/L (serum LDH 216 IU/L), fluid protein 2.5 mg/dl (serum total protein 6.4 mg/dl), glucose 138 mg/dl and WBC count 170/mm3. Cultures from the fluid unexpectedly grew cryptococcus neoformans. Lumbar puncture revealed a positive cryptococcal antigen in the CSF. Serum cryptococcal antigen was negative as were blood cultures. A pigtail chest tube was placed for continued drainage of the effusion for a total of 5 days, and he was started on anti-fungal therapy with amphotericin B and flucytosine per infectious disease recommendations. He clinically improved after about 1 week of treatment, and was discharged to a rehabilitation facility after being transitioned to oral fluconazole for a planned 6 month course for disseminated cryptococcoses. The patient was readmitted after 3 weeks with cardiogenic shock due to acute coronary syndrome, and unfortunately passed away soon after.
DISCUSSION: Pulmonary disease due to cryptococcus neoformans usually manifests radiographically as multiple nodules (often with cavitation), air space consolidations or ground-glass opacities1. Pleural effusions due to this organism are uncommon, and appear to result from extention of a primary subpleural nodule into the pleural space2. Furthermore, our literature review revealed that all of these pleural effusions were exudative, most of them being lymphocyte predominant3.
CONCLUSIONS: We present possibly the first reported case of a transudative pleural effusion due to cryptococcus neoformans in an elderly patient on hemodialysis
Reference #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 Feb;129(2):333-40.
Reference #2: Salyer WR, Salyer DC. Pleural involvement in cryptococcosis. Chest. 1974 Aug;66(2):139-40.
Reference #3: Light,R.W. Pleural Diseases, 2006 (p. 266)
DISCLOSURE: The following authors have nothing to disclose: Rahul Sood, Paulo Oliveira, Scott Ferrara
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