Chest Infections: Fellow Case Report Poster - Chest Infections I |

An Unusual Case of Crypotococcal Pleural Effusion FREE TO VIEW

Aditya Chada, MBBS; Krishna Siva Sai Kakkera, MBBS; Anwar Rjoop, MD; Nikhil Meena, MD
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University of Arkansas for Medical Sciences, Little Rock, AR

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):115A. doi:10.1016/j.chest.2016.08.124
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SESSION TITLE: Fellow Case Report Poster - Chest Infections I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Cryptococcus is a common cause of fungal infections in the immunocompromised patients. We wish to present an unusual case of recurrent pleural effusions in an immunocompetent patient because of Cryptococcal infection.

CASE PRESENTATION: A 58 year old male African American man with past medical history of suspected Lupus well controlled on Hydroxychloroquine, Chronic Hepatitis B was seen in pulmonary clinic for recurrent left sided pleural effusion. He was never on any other immunomodulatory therapy or steroids. Thoracentesis was done with fluid LDH of 1221 IU/dl, Protein of 6.6 gm/dl indicating an exudative collection. Bacterial, fungal, AFB smear and other studies were negative. He felt better after the procedure and the pleural effusion was attributed to Lupus serositis. Subsequent follow up in clinic revealed re-accumulation and worsening symptoms. He underwent Pleuroscopy with pleural biopsy. Pleural biopsy was positive for necrotizing pleuritis with Cryptococcus visible on GMS stain. HIV testing was negative and CSF was negative for meningitis. He was started on Oral Ketoconazole for 9 months and has done well since treatment initiation.

DISCUSSION: Cryptococcus is a prominent cause of lung and CNS infections in immunocompromised population. It is the fourth most common opportunistic infection in HIV infected patients. Cryptococcus gattii and neoformans account for majority of human infections. Infections in immunocompetent hosts are reported but more often for Cryptococcus gattii. Growth of organism in culture or direct visualization of organism on specimen is the most specific way of diagnosis. Serological testing with CSF/Serum antigen assays have high sensitivity (90%) and specificity. An isolated occurrence of Cryptococcal pleuritis with no pulmonary parenchymal lesions, as was seen in the present case is very rare.

CONCLUSIONS: In patients with recurrent pleural effusions Cryptococcus should be part of the differential. Further studies need to be done to better understand the pathogenesis of the same.

Reference #1: Emergence of cryptococcal disease: epidemiologic perspectives 100 years after its discovery. Hajjeh RA, Brandt ME, Pinner RW. 1995; Epidemiol Rev., p. 17(2):303.

Reference #2: Chen, Mayun et al. “Pleural Effusion as the Initial Clinical Presentation in Disseminated Cryptococcosis and Fungaemia: An Unusual Manifestation and a Literature Review.” BMC Infectious Diseases 15 (2015): 385. PMC. Web. 4 Apr. 2016.

DISCLOSURE: The following authors have nothing to disclose: Aditya Chada, Krishna Siva Sai Kakkera, Anwar Rjoop, Nikhil Meena

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