대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Cryptococcosis in a Patient with Renal Transplantation

Radiologic Findings

Chest x-ray shows ill-defined mass-like consolidation on LUL with eccentric cavitation or air-lucency. Chest CT shows 3.5 x 2cm sized nodule on left upper apicoposterior segment. Spiculated irregular border and peripheral cavity is visible within the nodule. Mediastinal lymph nodes are enlarged on perivascular area. Multiple lymph nodes are seen on prevascular, AP window, right paratracheal and subcarinal areas(not-shown).

The diagnosis of cryptococcal pneumonia was made by transthoracic needle aspiration and culture for the parenchymal lesion.

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.

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, Fungal infection, immune related,