Cryptococcal cavitary pneumonia in an immunocompetent patient

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Date: June 2008
From: Journal of Respiratory Diseases(Vol. 29, Issue 6)
Publisher: CMP Medica, LLC
Document Type: Case study
Length: 1,963 words
Lexile Measure: 1320L

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Cryptococcus neoformans most commonly infects persons with an underlying T-cell immunodeficiency. It has been nicknamed the "sugarcoated killer" because it can cause a devastating disseminated illness in immunosuppressed patients. C neoformans rarely causes primary infection in an immunocompetent patient. We present a case of pulmonary cryptococcosis that occurred in an otherwise healthy man.

The case

A 26-year-old emergency medical technician presented to a community hospital emergency department with a cough of 6 weeks' duration and pleuritic chest pain. The cough was initially dry but became productive of yellow blood-tinged sputum 3 days before presentation. He had completed a 10-day course of amoxicillin therapy without clinical improvement.

The patient had had a cholecystectomy 1 year earlier and had no other medical history. He was not taking any medications and was allergic to sulfonamides. He was a lifelong nonsmoker, denied any history of drug or alcohol use, and had no known risk factors for HIV infection. The results of annual tuberculin skin testing had never been reactive, and he had no known exposure to infectious tuberculosis. His family history was noncontributory. Physical examination revealed a well-nourished, nontoxic-appearing man with normal vital signs. Pulmonary, cardiac, and abdominal examination findings were normal, and there were no focal neurological deficits. The patient's complete blood cell count and the results of a basic metabolic panel and liver function tests were normal on admission.

A chest radiograph revealed multiple cavitary lesions in the right upper lobe (Figure 1). A subsequent CT scan of the chest revealed multiple patchy areas of consolidation with cavitation most notable in the right lung (Figure 2A).

The patient was admitted to the general medicine floor with airborne precautions. Initial antibiotic therapy was withheld in the hopes of identifying a specific pathogen. The results of tuberculin skin testing and tests for HIV, Coccidioides antibody, proteinase 3 antibody, and myeloperoxidase antibody were negative.

Because the patient's sputum and blood cultures were nondiagnostic, flexible fiberoptic bronchoscopy was performed. Bronchoalveolar lavage (BAL) of the right upper lobe revealed no organisms on direct examination; however, yeast grew on fungal culture (Figure 3). Yeast biochemical testing confirmed Cryptococcus neoformans as the pathogen.

A lumbar puncture was not performed because of the paucity of neurological signs and symptoms. The result of a serum Cryptococcus antigen test was positive, with a titer of 1:64. The patient was given oral fluconazole, 400 mg/d. He remained stable throughout his hospitalization, with resolution of his low-grade fever and a significant improvement in his cough and chest pain. He was discharged to home on a regimen of antifungal therapy.

After 4 weeks of fluconazole therapy, the patient's cough, hemoptysis, and pleuritic chest pain had resolved. A CT scan of the chest revealed significant improvement (Figure 2B). Of interest, his Cryptococcus antigen titer had increased to 1:254 after 4 weeks of therapy.

Discussion

C neoformans is an encapsulated yeast that is found worldwide. It first became associated with pigeons when it was found in soil...

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Gale Document Number: GALE|A180472157