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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 29-31

Pulmonary cryptococcosis presenting as miliary tuberculosis in an immunocompetent patient


Department of Pulmonary Medicine, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, India

Date of Submission26-Feb-2020
Date of Decision19-Jun-2020
Date of Acceptance31-Jul-2020
Date of Web Publication15-Feb-2021

Correspondence Address:
Dr. Ankit Bhatia
Department of Pulmonary Medicine, Max Super Speciality Hospital, Vaishali, Ghaziabad 201012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacp.jacp_5_20

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  Abstract 


Pulmonary Cryptococcosis is a rare and difficult to diagnose entity. It has been found to be associated with immunocompromised patients. Pulmonary Cryptococcosis in an immunocompetent patient is extremely rare condition. A high degree of suspicion is required to diagnose the condition. We hereby present a case of pulmonary cryptococcosis in an immunocompetent young male which is a rare clinical entity.

Keywords: Bronchoscopy, cryptococcosis, immunocompetence


How to cite this article:
Joshi S, Tayal N, Gupta R, Bhatia A, Kapoor N. Pulmonary cryptococcosis presenting as miliary tuberculosis in an immunocompetent patient. J Assoc Chest Physicians 2021;9:29-31

How to cite this URL:
Joshi S, Tayal N, Gupta R, Bhatia A, Kapoor N. Pulmonary cryptococcosis presenting as miliary tuberculosis in an immunocompetent patient. J Assoc Chest Physicians [serial online] 2021 [cited 2021 Mar 3];9:29-31. Available from: https://www.jacpjournal.org/text.asp?2021/9/1/29/309477




  Introduction Top


Cryptococcal infections are caused by the fungi Cryptococcus gattii and C. neoformans commonly found in, soil, bird droppings and decaying wood.[1] It is mostly found in immune compromised patients and is acquired by inhalation of aerosolized particles.[2] In immunocompetent host Cryptococcus usually remain as a commensal in tracheobronchial tree.[3] The most common radiographic findings in the immunocompetent host are single or multiple predominant peripheral based nodules.[4] We are here presenting a case of pulmonary cryptococcosis in an immunocompetent young male which is a rare clinical entity.


  Case Top


A 38 years male, farmer by occupation was admitted with complaints of high-grade fever (Upto 105 F), dry cough and breathlessness for 20 days. Patient did not have history of any chronic disease. He was given Anti tubercular treatment at another hospital on clinicoradiologial basis. On arrival in emergency, patient was conscious and oriented. His vital parameters were heart rate − 120/min, blood pressure − 120/80mm Hg, respiratory rate − 32/min, oxygen saturation − 88% on Rebreather Mask with Oxygen at the rate of 15 litres(L)/minute(min), body temperature 101 F. Systemic examination was normal except bilateral crepitations on chest auscultation. His Arterial Blood Gas analysis showed Hypoxemic respiratory failure (pH 7.464, PCO2-36.9, PO2-52.7, Hco3-26.1).

His blood investigations showed Haemoglobin: 11.1 g/dl, Total leucocyte count: 4540/cmm, platelet: 2,82,000/cumm, Serum Procalcitonin-1.22 IU, normal Kidney function test and Liver function test. Blood tests for Malaria (Peripheral Blood Film and Malaria Antigen test) and typhi dot were negative. His Chest X Ray showed bilateral nodular opacities in all zones [Figure 1]. His CT thorax showed extensive diffuse peribronchovascular thickening with nodularity in bilateral lungs. Bilaterally symmetrical dependant posterior consolidation like changes and areas of ground glass opacity in lower and peripheral aspects on both sides [Figure 2]. As the patient continued to be febrile and all microbiological investigations were normal(Sputum Acid fast bacilli smear negative, pyogenic culture negative), Fibreoptic Bronchoscopy was done [Figure 3]. Bronchoalveolar lavage(BAL) and Transbronchial Lung biopsy (TBLB) was taken. Histopathology of TBLB [Figure 4] showed a few round to oval encapsulated yeast-like fungal structures. The Fungal structures identified on H&E stain were positive for PAS and Methenamine staining suggestive of cryptococcal infection. BAL sent for microbiological investigations did not show any bacterial infection. So a diagnosis of Cryptococcal pneumonia was made. Treatment with Antifungal medication (Liposomal Amphotericin) was started. Patient’s condition improved dramatically. He became afebrile within next 12 hours and could maintain oxygen saturation of 90% on oxygen supplementation through Face Mask at a flow of 5 L/min. We treated with Amphotericin B (150 mg/day infusion) for 2 weeks followed by Oral Fluconazole 400 mg/day for 10 weeks.
Figure 1 X Ray chest s/o bilateral nodular opacities in all zones.

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Figure 2 Extensive diffuse peribronchovascular thickening with nodularity in bilateral lungs.

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Figure 3 Bronchoscopic image TBLB from RLL.

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Figure 4 H&E stain showing encapsulated yeast like fungal structures.

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  Discussion Top


Cryptococcus neoformans is an encapsulated, round to oval yeast. It is surrounded by a polysaccharide capsule. There are two pathogenic variants: C. neoformans var. neoformans and C. neoformans var. gattii.[5] Cryptococcal infections occur predominantly in patients with T-cell mediated immune defects.[6] The majority of cases of cryptococcal disease occur in persons with a CD4 cell count below 200 cells/µL, usually below 50 cells/µL.[5]

Cryptococcal infection which is limited to the lung is defined as primary pulmonary cryptococcosis. Symptoms and radiologic findings of pulmonary cryptococcosis are non-specific.[7] The presentation of pulmonary cryptococcosis can range from asymptomatic nodular disease to severe acute respiratory distress syndrome (ARDS).[8] Immunocompetent subjects with pulmonary cryptococcosis are mostly asymptomatic or have mild symptoms that include fever, cough, sputum, myalgia, and dyspnea.[9] Few case reports have shown that pulmonary cryptococcosis may even present as lung mass mimicking malignancy.[3]

Diagnosis of lung cryptococcosis is based on isolation of Cryptococcus from, or detection of cryptococcal antigen in, a pulmonary specimen, along with appropriate clinical, radiological, and histopathological findings. Most common CT finding are pulmonary nodules/masses, either solitary or multiple, associated findings included CT halo sign, cavitation, and air bronchogram. Areas of consolidation, areas of Ground glass opacities, linear opacities, lymphadenopathy, and pleural effusion were uncommon. Cavitations within nodules/masses were more frequently present in immunocompromised patients whereas immunocompetent patients mostly present with Air bronchogram within nodules/masses.[10]

Various diagnostic modalities have been studied for pulmonary cryptococcosis. Both TBLB and percutaneous lung biopsy are less invasive, economical and practical although smaller tissue samples are obtained. Zhang et al.[11] showed that 85.53% lesions of pulmonary cryptococcosis are located in the peripheral regions of the lungs and percutaneous lung biopsy is relatively simple, less invasive and effective in such patients. So with a diagnosis rate of 74% to 95%, percutaneous lung biopsy may be the preferred initial biopsy method.[12]

Patients with pulmonary cryptococcosis should be evaluated in accordance with the patient’s immune status and for the extent of systemic spread.[13] Majority of immunocompetent asymptomatic patients with pulmonary cryptococcosis may undergo spontaneous remission.[11] Immunocompetent patients with mild to moderate pulmonary cryptococcal infection without diffuse infiltrates can be treated with six to 12 months of 400 mg oral fluconazole daily. In patients with meningoencephalitis, disseminated disease, severe pulmonary disease with diffuse infiltrates, or those who are immunocompromised, the treatment is 14 days of induction with flucytosine and amphotericin B, followed by six to 12 months of maintenance fluconazole.[13]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nadrous HF, Antonios VS, Terrell CL, Ryu JH. Pulmonary cryptococcosis in non-immunocompromised patients. Chest 2003;124:2143-7.  Back to cited text no. 1
    
2.
Kim YS, Lee IH, Kim HS, Jin SS, Lee JH, Kim SK et al. Pulmonary cryptococcosis mimicking primary lung cancer with multiple lung metastases. Tuberculosis and Respiratory Diseases 2012;73  Back to cited text no. 2
    
3.
Babu AK, Gopalakrishnan R, Sundararajan L, Pulmonary cryptococcosis: an unusual presentation. Lung India 2013;30:347-50.  Back to cited text no. 3
    
4.
Mitchell T, Perfect J. Cryptococcosis in the era of AIDS: 100 years after the discovery of Cryptococcus neoformans. Clin Microbiol Rev 1995;8:515-48.  Back to cited text no. 4
    
5.
Huang L, Crothers K. HIV-associated opportunistic pneumonias. Respirology 2009;14:474-85  Back to cited text no. 5
    
6.
Nadrous HF, Antonios VS, Terrell CL, Ryu JH. Pulmonary cryptococcosis in nonimmunocompromised patients. Chest 2003;124:2143-7.  Back to cited text no. 6
    
7.
Sung JH, Kim DH, Oh MJ, Lee KJ, Young M, Bae A, Kwon KW et al. A case of pulmonary cryptococcosis in an immunocompetent male patient diagnosed by a percutaneous supraclavicular lymph node biopsy. Tuberc Respir Dis 2015;78:276-80  Back to cited text no. 7
    
8.
Saag MS, Graybill RJ, Larsen RA, Pappas PG, Perfect JR, Powderly WG et al. Practice guidelines for the management of cryptococcal disease. Infectious Diseases Society of America. Clin Infect Dis 2000;30:710-8.  Back to cited text no. 8
    
9.
Smith JA, Kauffman CA. Pulmonary fungal infections. Respirology 2012;17:913-26.  Back to cited text no. 9
    
10.
Xie LX, Chen YS, Liu SY, Shi YX. Pulmonary cryptococcosis: comparison of CT findings in immunocompetent and immunocompromised patients. Acta Radiol 2015;56:447-53. doi: 10.1177/0284185114529105. Epub 2014 Apr 22.  Back to cited text no. 10
    
11.
Zhang Y, Li N, Zhang Y, Chen HX, Wang S et al. Clinical analysis of 76 patients pathologically diagnosed with pulmonary cryptococcosis, Eur Respir J 2012;40:1191-200  Back to cited text no. 11
    
12.
Vilchez RA, Irish W, Lacomis J et al. The clinical epidemiology of pulmonary cryptococcosis in non-AIDS patients at a tertiary care medical centre. Medicine 2001;80:308-12.  Back to cited text no. 12
    
13.
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. Clin Infect Dis 2010;50:291-322.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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