Abstract We present a case of a 63-year-old male who presented to the Emergency Room with the chief complaint of a nonproductive cough over the last two weeks with dyspnea, fevers and left shoulder pain and ultimately found to have cryptococcus pneumonia complicated by an empyema requiring decortication. Pulmonary cryptococcus rarely causes severe respiratory disease in immunocompetent patients. Complications consist of pleural effusions, superior vena cava (SVC) obstruction, and invasion into the chest wall. CT chest demonstrated a moderately sized left-sided complicated pleural effusion with air-fluid levels and associated consolidative changes throughout the left lung. A pigtail catheter was subsequently placed and tPA/Dornase administered. Repeat imaging showed persistent hydropneumothorax and the chest tube continued to have high-volume output. Thoracic surgery performed decortication. A bronchoscopy with bronchoalveolar lavage(BAL) was performed followed by a thoracotomy lung decortication. Several pockets of purulent fluid were evacuated and adhesions removed. The patient was found to have a fibrothorax, left lower lobe cavitary lesion, with empyema. The BAL fluid cultures grew cryptococcus neoformans. The pleural fluid cultures were negative. Pleural biopsies showed fibrous tissue with diffuse chronic and acute inflammation. Lung biopsies of the pulmonary cavitation showed organizing pneumonia. Cryptococcus antigen from the serum and CSF were negative. Pulmonary cryptococcus can occur in immunocompetent patients. Commonly presenting with typical pneumonia symptoms including cough, hemoptysis, chest pain, dyspnea, fever, malaise, night sweats. Rare manifestations also include obstruction of the SVC, pancoast syndrome due to granulomatous inflammation, eosinophilic pneumonia and extension of the infection into the chest wall. Asymptomatic infections can also be detected and are often incidentally discovered usually while undergoing work-up for malignancy due to initial radiographic findings. Typical radiographic findings of pulmonary cryptococcus in immunocompetent patients consist of noncalcified nodules, often pleural based, or lobar infiltrates, pleural effusions, and cavitations. Radiographic findings are usually more severe in immunosuppressed patients. Pleural effusions are usually exudative, with culture positivity. Cryptococcal antigen is a sensitive and specific test in immunocompromised patients. However in immunocompetent patients, antigen detection is not as sensitive, especially for pulmonary infection. While isolated pulmonary cryptococcal disease in immunocompetent patients is uncommon, it can still cause complications such as SVC syndrome, pancoast syndrome, or require surgical intervention due to involvement of the pleural space and chest wall. It’s important to remember that cryptococcal antigen testing can aid in the diagnosis however in immunocompetent patients the sensitivity decreases and can subsequently be non-diagnostic. This abstract is funded by: None
Dias et al. (Fri,) studied this question.