대한흉부영상의학회 Weekly Chest Cases

Case No : 891 Date 2014-11-24

Courtesy of Chul Hwan Park, Tae Hoon Kim / Gangnam Severance Hospital
Age/Sex 72 / F
Chief ComplaintAbnormality found on follow-up CT, PHx: S/P Right lower lobe lobectomy due to primary lung cancer(adenocarcinoma, papillary dominant, T1bN0M0)(2012)

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Preoperative CT(2012)

Diagnosis With Brief Discussion

Diagnosis: Cryptococcosis
Radiologic Findings: Chest radiography taken on Jan, 2014 showed multiple small nodular lesions in left lower lung field. On CT, multiple tiny or small nodules were located in the left upper lobe (LUL) and right upper lobe. Most of the nodules were clustered in the LUL. Some of them were round but others showed irregular shape. The largest one measured about 1.5 cm. On PET-CT, multiple nodules in LUL showed considerable FDG uptake, suggesting hyper-metabolic state.

Wedge resection was performed at the LUL. The pathologic diagnosis was cryptococcosis with chronic granulomatous inflammation (GMS, PAS, D-PAS : positive, AFB: negative)
Brief Review: Cryptococcus neoformans, a ubiquitous encapsulated fungus, is the cause of pulmonary cryptococcosis. Cryptococcal infection usually starts with inhalation of organism from environmental source, which is uncommon in immnocompetent hosts. Radiologic manifestations of pulmonary cryptococcosis are various and consist of 1) solitary pulmonary nodule or mass, 2) segmental or lobar consolidation, and 3) small nodular or reticulonodular pattern. Zinck et al. reported that pulmonary nodules were the most common CT findings (91%) and associated findings were masses, CT halo sign, and consolidation in 11 patients (7: immunocompromised, 4: immunocompetent). Mediastinal lymphadenopathy, pleural effusion, cavitation, mass and consolidation are more common in immunocompromised patients. When pulmonary cryptococcosis appears as multiple nodules in immunocompetent patients, they can mimic hematogeneous metastasis because the lesions show random distribution with peripheral predominance. However, cryptococcal nodules tend to cluster in one or few lobes, just like our case. If the FDG uptake of nodules is low, this finding might support the low possibility of metastasis. However, the range of FDG uptake of cryptococcal nodule is wide, with SUVmax varying from 0.93-11.6.
References: 1. Khoury MB, Godwin JD, Ravin CE, Gallis HA, Halvorsen RA, Putman CE. Thoracic cryptococcosis: immunologic competence and radiologic appearance. AJR Am J Roentgenol 1984;142:893-896
2. Zinck SE, Leung AN, Frost M, Berry GJ, Muller NL. Pulmonary cryptococcosis: CT and pathologic findings. J Comput Assist Tomogr 2002;26:330-334
3. Lindell RM, Hartman TE, Nadrous HF, Ryu JH. Pulmonary cryptococcosis: CT findings in immunocompetent patients. Radiology 2005;236:326-331
4. Song KD, Lee KS, Chung MP, Kwon OJ, Kim TS, Yi CA, et al. Pulmonary cryptococcosis: imaging findings in 23 non-AIDS patients. Korean J Radiol 2010;11:407-416
5. Ghimire P, Sah AK. Pulmonary cryptococcosis and tuberculoma mimicking primary and metastatic lung cancer in 18F-FDG PET/CT. Nepal Med Coll J 2011;13:142-143
6. Guimaraes MD, Marchiori E, de Souza Portes Meirelles G, Hochhegger B, Santana PR, Gross JL, et al. Fungal infection mimicking pulmonary malignancy: clinical and radiological characteristics. Lung 2013;191:655-662
7. Lee CH, Tzao C, Chang TH, Chang WC, Huang GS, Lin CK, et al. Case of pulmonary cryptococcosis mimicking hematogeneous metastases in an immunocompetent patient: value of absent 18F-fluorodeoxyglucose uptake on positron emission tomography/CT scan. Korean J Radiol 2013;14:540-543
8. Suwatanapongched T, Sangsatra W, Boonsarngsuk V, Watcharananan SP, Incharoen P. Clinical and radiologic manifestations of pulmonary cryptococcosis in immunocompetent patients and their outcomes after treatment. Diagn Interv Radiol 2013;19:438-446
Keywords: Lung, Infection, Fungal infection,

No. of Applicants : 67

▶ Correct Answer : 17/67, 25.4%

- Seoul National University Hospital , Korea (South) Sang Min Lee
- DAYA General Hospital,Thrissur,Kerala , India Raveendran TK
- Oita University, Faculty of Medicine , Japan Fumito Okada
- Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
- Government Medical College, Nagpur, India , India Krishna Prasad Bellam
- Niigata City General Hospital , Japan Takao Kiguchi
- SNUH , Korea (South) Eui Jin Hwang
- Asan medical center , Korea (South) Sang Young Oh
- National Hospital Organization Okinawa Hospital , Japan Yasuji Oshiro
- CHU POITIERS , France SZTARK Guillaume
- CHU Poitiers , France CHAN paul
- University of Tsukuba Hospital , Japan Sodai Hoshiai
- The University of Tokyo Hospital , Japan Takeyuki Watadani
- CLINIQUE STE CLOTILDE , Reunion patrick MASCAREL
- Onomichi municipal hospital , Japan Hirofumi Mifune
- Ishikawa Matto Central Hospital , Japan Manabu Akimoto
- jaslok hospital & research centre mumbai , India JAINENDRA JAIN

▶ Correct Answer as Differential Diagnosis : 16/67, 23.9%

- Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
- The University of Tokyo Hospital , Japan Akifumi Hagiwara
- The University of Tokyo Hospital , Japan Toshihiro Furuta
- Kyoto University , Japan Akihiko Sakata
- Kizawa Memorial Hospital , Japan Yo Kaneko
- VHS medical center , Korea (South) Seong hee Jeon
- Kyung Hee University Hospital at Gangdong , Korea (South) Seong Jong Yun
- IRSA La Rochelle , France Denis Chabassiere
- GHICL , France manuel toledano
- Northern Yokohama Showa university , Japan Kota Watanabe
- Gifu Central Hospital , Japan Haruo Watanabe
- Seirei Hamamatsu General Hospital , Japan Kenichi Mizuki
- Shiga University of Medical Science , Japan Akitoshi Inoue
- National Center hospital of Neurology and Psychiatry , Japan Kaoru Sumida
- ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
- Kobe City Medical Center General Hospital , Japan Yasuhisa Kurata

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 891 Date 2014-11-24

Discussion

No. of Applicants : 67