Abstract Intro Cryptococcus neoformans infection presenting as rapidly re-accumulating unilateral pleural effusion in immunocompetent host, a rare presentation of pulmonary cryptococcal disease. While usual presentation as meningitis in immunocompromised patient populations, we present a rare case of unilateral recurrent effusion as the initial presentation of cryptococcal disease in an immunocompetent patient. Case Report An 85-year-old male with past medical history of hypertension, hyperlipidemia, diabetes mellitus, chronic kidney disease stage IIIb, coronary artery s/p stent placement in 2nd obtuse marginal branch of the circumflex artery presented to emergency department with dyspnea on exertion and unintentional 30-pound weight loss over 2-3 months. Prior occupation included work in a tire factory, he denied exposure to asbestos. He chews tobacco and has a dog. Chest radiograph with evidence of large right-sided pleural effusion. He required repeated thoracentesis and pigtail chest tube placements over four hospital admissions. Review of initial cytology, extensive serology, pleural fluid analysis, gram stain, culture, HIV, adenosine deaminase were all negative. Given recurrent hospitalizations and repeat accumulation of right pleural effusion as seen in Image 1, the decision was made to undergo endobronchial ultrasound which demonstrated lymphocytosis without evidence of malignancy. Bronchoalveolar lavage grew 100 colonies of cryptococcus neoformans. He underwent lumbar puncture with opening pressure of 37 and negative cryptococcal antigen. He was started on fluconazole 400mg daily upon discharge with suspected treatment course of 12 months with close pulmonology follow-up outpatient. Discussion Pulmonary cryptococcus neoformans infection is a rare presentation of cryptococcus among immunocompetent hosts. To our knowledge, there’s less than 6 cases of pulmonary cryptococcal infection presenting as unilateral pleural effusion. While symptoms are often nonspecific such as dyspnea, there were no large differences in symptom presentation among immunocompetent and immunocompromised patients; however, computed tomography findings of mediastinal lymphadenopathy and cavitary lesions are often more prominent in immunocompromised patient populations. While typical risk factors include exposure to bird droppings/native colonizers of soil, our patient likely had exposure via inhalation of spores from the environment with direct mycosis infection of the parenchyma with visceral pleural involvement isolating the disease burden to local infection as opposed to disseminated (CNS involvement). When clinical suspicion for cryptococcal infection remains high, prompt evaluation with bronchoalveolar lavage and subsequent lumbar puncture should be performed to evaluate for isolated pulmonary disease compared to disseminated disease. Our case is a rare initial presentation of cryptococcal neoformans presenting as recurrent unilateral pleural effusion. This abstract is funded by: None
Gacutan et al. (Fri,) studied this question.