대한흉부영상의학회 Weekly Chest Cases

Case No : 388 Date 2005-04-02

Courtesy of Ok Hee Woo, M.D., Hwan-Seok Yong, M.D., Eun-Young Kang, M.D. / Korea University Guro Hospital, Seoul, Korea
Age/Sex 38 / F
Chief ComplaintHeadache for two months. No previous medical history

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Diagnosis With Brief Discussion

Diagnosis: Cryptococcosis in immunocompetent host
Radiologic Findings: Initial chest radiograph (Fig. 1) shows poorly defined opacity in right apical lung. Chest CT scan (Fig. 2, 3) shows lobulating contoured nodule with internal cavity and surrounding linear densities on RUL. Brain MRI shows multiple ring-enhancing lesions with vasogenic edema in cerebellum, right temporal, both frontal and left perirolandic area.
Brief Review: Pulmonary infection with Cryptococcus neoformans can be aymptomatic and subclinical, mild and self-limited in immunocompetent hosts. When symptoms do occur they are usually indolent, progressing over a course of weeks to months. In most cases, patients with pulmonary cryptococcosis do not become symptomatic until pulmonary lesions have become very large. As a consequence, many cases are found incidentally on chest radiograph or CT.

There are 4 primary patterns of radiographic findings in immunocompetent hosts: pulmonary nodules, fungus collections, cryptococcal pneumonia, and disseminated disease. Approximately one third to one half of cases of pulmonary cryptococcosis in immunocompetent hosts define by pulmonary nodules, which are usually subpleural, solitary or clustered. Segmental pneumonia, miliary nodules, cavitation, lymphadenopathy, and pleural effusions are less common in immunocompetent hosts. The recent report regarding to HR CT manifestations described multiple nodules including surrounding centrilobular nodules without “tree-in-bud” appearance.

Diagnosis can be established based on identification of the characteristic yeast-like organism with capsule in tissue with India ink, silver or mucicarmine stain. Diagnosis of pulmonary cryptococcosis can be established by transbronchial or transthoracic biopsy.

In immunocompetent hosts, the natural history of the disease typically results in spontaneous resolution within 1 to 2 months even in the absence of therapy.
References: 1. Murayama S et al. Pulmonary cryptococcosis in immunocompetent patients HRCT characteristics. Clinical Imaging 2004;28:191-195

2. Himmel, J. E. and P. Stark. Cryptococcal pneumonia in an immunocompetent host: radiographic findings. Semin Respir Infect 2003;18: 129-31.
Keywords: Lung, Infection, Fungal infection,

No. of Applicants : 35

▶ Correct Answer : 22/35, 62.9%

- Annecy Hospital, France Gilles Genin
- Annemasse, Polyclinique de Savoie, France Gay-Depassier Philippe
- ASL BOLOGNA Maggiore Hospital, Bologna, Italy Marcellino Burzi
- CHU Besancon, France Sebastien Aubry
- CHU Besancon, France Puget Julien
- CIM Saint Dizier, France JC Leclerc
- Dong-A University Hospital, Korea Ki-Nam Lee
- European Hospital, Paris, France Rached Triki
- Ev. Krkhs. Hubertus, Berlin, Germany Michael Weber
- Gwangmyoung Sung-Ae Hospital, Korea Jiyong Rhee
- Hangang SacredHeart Hospital, Korea Eil Seong Lee
- Hanyang University Hospital, Seoul, Korea Yo Won Choi
- Homs National Hospital, Homs, Syria Rami Abou Zalaf
- Incheon Sarang Hospital, Korea Jung Hee Kim
- Kyunghee University Hospital, Korea Su Youn Sim
- Max Hospital, Delhi, India Vickrant Malhotra
- Samsung Medical Cneter, Korea Ha Young Kim
- Shinmasan Hospital, Korea Kyung Hwa Jung
- Social Security Hospital, Ankara, Turkey Meric Tuzun
- University Hospital of Ghent Kristof De Cuyper
- Wagga Medical Imaging, Australia Rashid Hashmi
- Yon sei Univ. Hospital, Korea EunHye Yoo

▶ Semi-Correct Answer : 2/35, 5.7%

- Busan Veterans Hospital, Korea Suhku Huh
- Ping Tung Christian Hospital,Taiwan Jun-Jun Yeh

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 388 Date 2005-04-02

Discussion

No. of Applicants : 35