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Weekly Chest CasesArchive of Old Cases

Case No : 964 Date 2016-04-18

  • Courtesy of Hyun Jung Yoon, Yo Won Choi, Seok Chol Jeon / Hanyang University Hospital
  • Age/Sex 53 / F
  • Chief ComplaintCough, sputum
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5

Diagnosis With Brief Discussion

Diagnosis
Pulmonary cryptococcosis
Radiologic Findings
On initial chest radiograph, peribrochial patchy consolidation with multiple ill-defined subpleural nodular lesions is seen in the left lung, and the lesions were not changed on follow-up radiograph taken two weeks later. CT scan of the chest demonstrates ill-defined subpleural nodules and peribronchial consolidation with surrounding halo.
Percutaneous CT-guided needle biopsy was performed. Pathologic findings revealed chronic granulomatous inflammation with numerous yeast-form fungal organisms. Periodic acid–Schiff, Grocott's methenamine silver and mucicarmine staing results were positive, consistent with pulmonary cryptococcosis.

H&E stain

Mucicarmine stain

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. Cryptococcal infections are most common in immunocompromized patients such as those with AIDS, who underwent organ transplantation, or who have a hematologic malignancy. These infections are relatively rare in immunocompetent patients.
Pulmonary cryptococcosis in AIDS patients tends to manifest as a disseminated thoracic disease with an interstitial lung pattern and lymph node enlargement. However, pulmonary cryptococcosis is an indolent lung disease in non-AIDS patients that is slowly progressive in nature, even without adequate treatment. Moreover, the lung abnormalities donot show rapid resolution even with antifungal therapy.
The disease in immunocompetent patients may show various patterns of lung lesions; however, A clustered nodular pattern, localized to a lung lobe, is the most common abnormality. Therefore, lung lesions of single or multiple nodules or a mass, for this condition, may persist and may simulate malignant disease, a chronic inflammatory or an infectious disease, or a metastatic lesion, particularly when patients have an underlying extra-thoracic malignancy.
In half of the cases, the disease appeared in patients with underlying disease, in which most of the patients had an extra-thoracic malignant condition. Therefore, when lung lesions show clustered or scattered nodules of an indolent nature, pulmonary cryptococcosis should be considered in the differential diagnosis, even for a patient with an extrathoracic malignancy. Although clinical improvement can be achieved in all patients, radiological improvement is slow, even after antifungal therapy.
References
1. Song KD, Lee KS, Chung MP, Kwon OJ, Kim TS, Yi CA, Chung MJ. Pulmonary cryptococcosis: imaging findings in 23 non-AIDS patients. Korean J Radiol. 2010 ;11(4):407-416.
2. Lindell RM, Hartman TE, Nadrous HF, Ryu JH. Pulmonary cryptococcosis: CT findings in immunocompetent patients. Radiology. 2005;236(1):326-331.
Keywords
Lung, Infection, Fungal infection,

No. of Applicants : 110

▶ Correct Answer : 21/110,  19.1%
  • - Niigata University , Japan Atsushi Uehara
  • - Shiga University of Medical Science , Japan Akitoshi Inoue
  • - Juntendo University Hospital , Japan Akifumi Hagiwara
  • - Policlinico Umberto I , Italy Paolo Baldassari
  • - Busan national univercity hospital radiology department , Korea (South) Il-wan Son
  • - Asan Medical Center , Korea (South) Hyung Jung Koo
  • - The Jikei university , Japan Taku Gomi
  • - The University of Tokyo Hospital , Japan Toshihiro Furuta
  • - Kizawa Memorial Hospital , Japan Yo Kaneko
  • - Chonnam National University Hospital , Korea (South) So yeon Ki
  • - University of Tsukuba Hospital , Japan Hiroaki Takahashi
  • - Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
  • - Himeji Redcross Hospital , Japan Soichiro Okamoto
  • - Daejin Medical Center Bundang Jesaeng General Hospital , Korea (South) Donghwan Kim
  • - Maternity & child hospital , Saudi Arabia Sania ALBlushi
  • - The University of Tokyo Hospital , Japan Kaoru Sumida
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - University of Tsukuba , Japan Toshitaka Ishiguro
  • - Kyoto University , Japan Akihiko Sakata
  • - the first affiliatited hospital of nanjing medical univercity , China Hai Xu
  • - Asan medical center , Korea (South) Cherry Kim
▶ Correct Answer as Differential Diagnosis : 13/110,  11.8%
  • - Saitama-Sekishinkai Hosptal , Japan Mihoko Yamazaki
  • - Ostu Municipal Hospital , Japan Noriatsu Ichiba
  • - okayama university , Japan numa shingo
  • - ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
  • - Eren Hastanesi Istanbul , Turkey Armagan Sarac
  • - Okayama University Hospital , Japan Toshiyuki Komaki
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - CHU Poitiers , France CHAN paul
  • - GHICL , France manuel toledano
  • - Kanto Rosai Hospital , Japan Taku Tajima
  • - NASA SCANS , India RAKESH BHATIA
  • - Diagnose.me (BV) / Royal Perth Hospital , Australia Yuranga Weerakkody
  • - Seirei Hamamatsu General Hospital , Japan Kenichi Mizuki
▶ Semi-Correct Answer : 2/110,  1.8%
  • - dayanand , India reena gupta
  • - MBAL BURGAS , Bulgaria VLADISLAV RUSINOV
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