대한흉부영상의학회 Korean Society of Thoracic Radiology

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Weekly Chest CasesCases by Disease Category

Case No : 1288 Date 2022-06-27

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  • Courtesy of Kum Ju Chae, Gong Yong Jin / Jeonbuk National University Hospital
  • Age/Sex 41 / M
  • Chief Complaintincidental abnormality detected on chest radiography
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6
  • Figure 7

Diagnosis With Brief Discussion

Diagnosis
Cryptococcosis
Radiologic Findings
Fig 1. Chest PA shows multifocal nodular opacity in the left lower lung field.
Fig 2-4. CT images showed multiple ill-defined nodules and nodular consolidations with peripheral ground-glass opacity (GGO).
Fig 5-7. After antibiotic therapy, follow-up CT after 3 weeks revealed aggravation of multiple nodular consolidations and GGOs.
He underwent VATS biopsy and pathologic findings showed chronic granulomatous inflammation due to cryptococcal infection.
Brief Review
Cryptococcus neoformans is a ubiquitous encapsulated yeast-like fungus that is found worldwide; particularly in soils that are contaminated with pigeon excreta and decayed wood. Inhalation of cryptococcal particles into the lungs is a route of pulmonary infection, and subsequent hematogenous dissemination may cause central nervous system infection. The infection usually affects immunocompromised patients, particularly those with an impaired cell-mediated immune response. Most immunocompetent individuals have mild or no clinical symptoms with isolated pulmonary involvement, otherwise more aggressive clinical and radiographic findings in immunocompetent patients.
Pulmonary cryptococcal infection has a variety of manifestations from lung nodules to mass-like appearance. The most common CT findings in immunocompetent patients with pulmonary cryptococcosis were pulmonary nodules. The nodules were most often multiple, smaller than 10 mm in diameter, and well defined with smooth margins. Nodules most commonly involved less than 10% of the parenchyma and were distributed in the middle and upper lungs. Multiple nodules were most commonly bilateral. Masses, areas of consolidation, cases of lymphadenopathy, pleural effusions, and areas of cavitation occurred infrequently. Pulmonary cryptococcosis in AIDS patients tends to manifest itself as a disseminated thoracic disease with an interstitial lung pattern and lymph node enlargement as seen in imaging studies. Although clinical improvement can be achieved in all patients, radiological improvement is slow, even after antifungal therapy. Lastly, lung lesions may persist for a long time, showing a divergence from the clinical response.
References
1. SUWATANAPONGCHED, Thitiporn, et al. Clinical and radiologic manifestations of pulmonary cryptococcosis in immunocompetent patients and their outcomes after treatment. Diagnostic and Interventional Radiology, 2013, 19.6: 438.
2. THAMBIDURAI, Lasya, et al. Cryptococcal pneumonia: the great mimicker. BJR| case reports, 2017, 20150358.
3. Lindell RM, Hartman TE, Nadrous HF, et al. Pulmonary cryptococcosis: CT findings in immunocompetent patients. Radiology. 2005 Jul;236(1):326-31.
4. Song KD, Lee KS, Chung MP, et al. Pulmonary Cryptococcosis: Imaging Findings in 23 Non-AIDS Patients. Korean J Radiol. 2010 Jul-Aug; 11(4): 407
Keywords
Cryptococcal Infection , Pulmonary cryptococcosis,

No. of Applicants : 87

▶ Correct Answer : 20/87,  23.0%
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - Showa General Hospital , Japan MASAFUMI KAIUME
  • - Kyoto University Hospital , Japan YUSUKE UTSUNOMIYA
  • - Tiger Gate Hospital , Japan SHIN-ICHI CHO
  • - Ichinomiya Nishi Hospital , Japan CHIHIRO KIGUCHI
  • - , China FANG YING GEN
  • - Oita University, Faculty of Medicine , Japan FUMITO OKADA
  • - Osaka University , Japan AKINORI HATA
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
  • - Kyoto University Hospital , Japan YASUHISA KURATA
  • - Ajou University Hospital , Korea (South) YOU NA KIM
  • - , Japan SHUNJIRO NOGUCHI
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - Eskisehir Sehir Hastanesi , Turkey MURAT SAHIN
  • - Osaka metropolitan university Hospital , Japan TATSUSHI OURA
  • - , Korea (South) KIM HYE IN
  • - Kyoto University Hospital , Japan SATOSHI IKEDA
  • - Toranomon Hospital , Japan KAORU SUMIDA
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
▶ Correct Answer as Differential Diagnosis : 12/87,  13.8%
  • - Jichi Medical University Hospital , Japan JUN KANZAWA
  • - ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
  • - Shiga University of Medical Science , Japan AKITOSHI INOUE
  • - , Italy PAOLO BALDASSARI
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Gifu University Hospital , Japan Yo Kaneko
  • - Other , Korea (South) CHAEHUN LIM
  • - , Qatar NABIL SHERIF MAHMOOD
  • - Chonnam National University Hwasun Hospital , Korea (South) JEONG YEOP LEE
  • - The University of Tokyo Hospital , Japan HIROSHI TAKUMIDA
  • - Jiangsu province hospital , China WANGJIAN ZHA
▶ Semi-Correct Answer : 6/87,  6.9%
  • - McGill University Health Center , Canada ALEXANDRE SEMIONOV
  • - , Korea (South) SUNHYANG LEE
  • - , Korea (South) YEONG UK HWANG
  • - , United Arab Emirates NEHAR RANJAN CHAKRABORTY
  • - Osmania Medical College, Hyderabad , India PURUSHOTHAMA RAO TUMMALA
  • - Chonbuk National University Hospital , Korea (South) DONG HAN SHIN
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