대한흉부영상의학회 Korean Society of Thoracic Radiology

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Weekly Chest CasesArchive of Old Cases

Case No : 282 Date 2003-03-22

  • Courtesy of Joon Beom Seo, M.D. / Asan Medical Center, Seoul, Korea
  • Age/Sex 64 / M
  • Chief ComplaintLiver transplantation 3 years ago due to HCC and LC. Incidental pulmonary nodules.
  • Figure 1
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  • Figure 4

Diagnosis With Brief Discussion

Diagnosis
Cryptococcosis in a Patient with Liver Transplantation
Radiologic Findings
Chest radiograph show small nodule in left lower lung zone. CT scan shows ovoid shaped nodule without calcification in lingular division of left upper lobe. Another nodule with caviation is noted in posterior subpleural portion of left lower lobe. Differential diagnoses include metastasis from hepatocellular carcinoma, cryptococcosis and posttransplantation lymphoproliferative disease.
Patient has been on medication of FK506, immunosuppressive drug. Wedge resection of the nodules revealed necrotizing granulomatous inflammation with yeast form fungi, consistent with cryptococcosis.
Brief Review
# Etiology : cryptococcus neoformans
# Epidemiology : worldwide distribution in soil and especially that containing pigeon & avian droppings
# Route of infection : inhalation of spores of fungus
# Principal involved sites : lung, CNS, blood, skin, bone, joints & prostate
# Clinical manifestations :
Cryptococcal infection can develop in both immunocompetent & immunocompromised hosts, but it may result in severe, disseminated disease in immunocompromised patients. Approximately one third of patients are asymptomatic, whereas the rest symptoms range from mild cough and low grade fever to acute, febrile, life-threatening condition, such as acute respiratory distress syndrome in compromised hosts. One half to two thirds of cases of symptomatic infection are related with AIDS. The disease can spread rapidly throughout lungs and disseminate to extrapulmonary sites, especially the meninges in immunocompromised patients.
Histopathologically, immunocompetent patients show granulomatous response, such as non-caseating granulomas or extensive caseation. In immunocompromised patients, intact alveolar spaces become filled with yeasts.

# Radiographic findings :
1) solitary or multiple nodular densities
2) segmental or lobar consolidation
3) cavitation within nodule (10-15%)
4) hilar & mediastinal lymphadenopathy, pleural effusion
5) in AIDS patients, nodules are uncommon and mediastinal & hilar lymphadenopathy is frequent.

# Diagnosis : Definite diagnosis is based on identification of characteristic yeast-like organism with capsule in tissue or fluid with India ink, silver or mucicarmine stain, together with cultural confirmation. In AIDS patients, BAL often will demonstrate organisms cytologically or by culture.

# Treatment: Do not need treatment, but amphotericin B, flucytosine is required in disseminated disease.
(From the Review of case 231)
References
1. Sarosi GA. Cryptococcal pneumonia. Semin. Respir. Infect. 1997 Mar; 12(1): 50-3
2. Woodring JH, Ciporkin G, Lee C, Worm B, Woolley S. Pulmonary cryptococcosis. Semin. Roentgenology. 1996 Jan; 31(1): 67-75
3. Friedman EP, Miller RF, Severn A, Williams IG, Shaw PJ. Cryptococcal pneumonia in patients with acquired immunodeficiency syndrome. Clin. Radiol. 1995 Nov; 50(11): 756-60
Keywords
Lung, Infection, immune related,

No. of Applicants : 32

▶ Correct Answer : 10/32,  31.3%
  • - CHU Nancy-Brabois, France Denis Regent
  • - Chung Li Ten-Chen Hospital,Taiwan Gui-Lin Zheng
  • - Chungju Hospital Konkuk University, Korea Chang Hee Lee
  • - Ewha Womans' University Hospital, Korea Sung Shine Shim
  • - Korean National Institute of Health, Korea Sang-Min Lee
  • - National Taiwan University Hospital, Taiwan Kao-Lang Liu
  • - Ospedale di Jesi, Italy Giancarlo Passarini
  • - Prever-Centro Radiologico, Brazil Arismar Leon Pereira
  • - Seoul National University Hospital, Korea Jung-Gi Im
  • - Tokyo Kouseinenkin Hospital , Japan Noriatsu Ichiba
▶ Semi-Correct Answer : 22/32,  68.8%
  • - Annecy Hospital, France Gilles Genin
  • - Asan Medical Center, Korea Eun Jin Chae
  • - Bharat Scans, Chennai, India R K Vaheesan
  • - CHRU Lille, France Philippe Dumont
  • - CHU Grenoble, France Mathieu Rodiere
  • - Dept of IM, Seoul National University Hospital, Korea Changmin Choi
  • - Ewha Hospital, Pusan, Korea Mi ok Sunwoo
  • - GeumGang Asan Hospital, Korea Ju Youn Park
  • - Hangang Sacred Heart Hospital, Korea Eil Seong Lee
  • - Incheon Sarang Hospital, Korea Jung Hee Kim
  • - Kangbuk Samsung Hospital, Korea Semin Chong
  • - Narayana Hrudayalaya, Bangalore, India PG Sridhar
  • - National Medical Center, Korea Sang Kyu Yang
  • - Ohio State University, Ohio, USA Sumit Seth
  • - Ondokuz Mayis University, Samsun, Turkey Cetin Celenk
  • - Samsung Medical Center, Korea Yeon Joo Jeong
  • - Samsung Medical Center, Korea Sun Young Jeong
  • - Shinmasan Hospital, Korea Jung Kyung Hwa
  • - Social Security Hospital, Ankara, Turkey Meric Tuzun
  • - Sunlin Hospital. Pohang, Korea Won Hyuk Shin
  • - Teleradiology Solutions, Bangalore, India Sharad Bidari
  • - Ulsan University Hospital, Korea Kwang-Won Seo
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