Disseminated cryptococcosis presenting as mediastinal and hilar lymphadenopathy in an immunocompetent patient

Diffuse Alveolar Hemorrhage Caused by Disseminated Cryptococcosis in a Patient With Systemic Lupus Erythematosus

A teenage girl with systemic lupus erythematosus (SLE) was admitted with fever, dry cough, and dyspnea on exertion. Chest computed tomography revealed bilateral diffuse infiltration and swelling of the mediastinal lymph nodes. The bronchoalveolar lavage (BAL) fluid was light red, suggesting diffuse alveolar hemorrhage (DAH). Therefore, glucocorticoid pulse therapy was initiated. However, blood and BAL fluid cultures showed the growth of Cryptococcus neoformans. The patient was diagnosed with disseminated cryptococcosis. The patient was treated with liposomal amphotericin B and flucytosine; the prednisolone dose was rapidly tapered. Infections should be thoroughly ruled out in patients with SLE and DAH.

[Diagnostic Value of Transbronchial Ultrasound-guided Needle Aspiration Biopsy in the Diagnosis of Small Cell Lung Cancer and Non-small Cell Lung Cancer]

背景与目的

纤维支气管镜腔内超声引导针吸活检术（endobronchial ultrasound guided transbronchial needle aspiration, EBUS-TBNA）作为近年来发展的新技术，具有操作简单、创伤小、准确率和安全性高及可重复性等优点，已成为进行肺癌诊断和纵隔分期的新标准。由于小细胞肺癌（small cell lung cancer, SCLC）和非小细胞肺癌（non-small cell lung cancer, NSCLC）的生物学特性以及治疗方案的不同，因此，在早期能诊断并鉴别的病理类型，对于肺癌的分期、治疗及预后均有很重要意义。本文探讨EBUS-TBNA在诊断SCLC和NSCLC中的准确率及敏感性。

方法

回顾性分析2012年1月-2018年12月首都医科大学宣武医院胸外科进行142例经支气管内超声引导针吸活检术患者的临床资料，选取最终确诊85例SCLC和NSCLC患者，比较两组差异。

结果

最终经免疫组化病理明确SCLC 45例，其中经EBUS-TBNA明确诊断为SCLC 42例，诊断准确率、敏感度分别为93.3%（42/45）、100.0%（42/42）。经细胞学检查明确诊断22例，诊断准确率为48.9%（22/45）；经病理明确诊断NSCLC 40例，其中经EBUS-TBNA明确诊断为NSCLC 35例，诊断准确率、敏感度分别为87.5%（35/40）、100.0%（35/35）。经细胞学检查明确诊断11例，诊断准确率为27.5%（11/40）；EBUS-TBNA在SCLC组的诊断准确率明显高于NSCLC组，且有统计学意义（P < 0.05）。

结论

EBUS-TBNA用于诊断SCLC较NSCLC的准确率高。EBUS-TBNA作为微创技术，可协助SCLC早期诊断，及时治疗。

An Elderly Patient with Pulmonary Cryptococcosis with Mediastinal Lymphadenopathy Who Was Successfully Treated with Amphotericin B and Flucytosine

Pulmonary cryptococcosis develops not only in immunocompromised patients but also in immunocompetent patients. However, lymph node involvement is relatively rare in immunocompetent patients. We herein report the case of an 80-year-old man who was not in an apparent immunocompromised state but was diagnosed with pulmonary cryptococcosis with mediastinal lymphadenopathy. The patient was resistant to fluconazole and voriconazole monotherapy; thus, his lung lesions significantly worsened. He eventually responded well to a combination therapy of amphotericin B and flucytosine, which was administered according to the treatment strategy for disseminated diseases.

Clinicopathological features of cryptococcal lymphadenitis and a review of literature

Cryptococcosis is an invasive fungal infection in immunocompromised patients. The clinicopathological characteristics of cryptococcal lymphadenitis are not well known. We analyzed three cases of cryptococcal lymphadenitis and compared their characteristics with those in previous reports. Two patients were human immunodeficiency virus (HIV) carriers, and one patient was a human T-cell leukemia virus type-1 (HTLV-1) carrier. The age of the HTLV-1 carrier with cryptococcosis was much higher than that of the HIV-1 carriers. CD4-positive cell counts in peripheral blood were 5.8/μL (Case 1) and 79.9/μL (Case 2) in the HIV carriers and 3285/μL in the HTLV-1 carrier (Case 3). According to flow cytometric analysis of the lymph nodes of Cases 1, 2, and 3, 50.0%, 87.1%, and 85.9%, respectively, of the T-cells were CD3; 9.8%, 16.3%, and 75.8%, respectively, were CD4; and 35.5%, 77.3%, and 10.2%, respectively, were CD8. Cryptococcus neoformans was detected in tissue culture in all patients. Although gelatinous lesions and numerous fungal cocci were observed in the two HIV patients, the granuloma formation was small. Gelatinous formation and granuloma formation were observed in the HTLV-1 carrier. Necrosis was observed in all cases. In previous reports, granuloma formation, epithelioid cells, and necrotic lesions were observed in most cases. Most of the patients were also immunosuppressed. However, no HTLV-1 carrier was detected. In conclusion, lymphadenopathy in a HTLV-1 carrier may suggest the presence of cryptococcal lymphadenitis. The frequency of cryptococcosis in HTVL-1 carriers may increase with increase in the long-term survival rate of HTLV-1 carriers.

Progressive cutaneous Cryptococcosis complicated with meningitis in a myasthenia gravis patient on long-term immunosuppressive therapy - a case report

BACKGROUND

Cryptococcosis is an opportunistic infection caused by the encapsulated yeast Cryptococcus neoformans and most remarkably manifests in HIV-infected individuals, especially in the settings of very low CD4 count. Development of cryptococcosis in HIV-uninfected individuals is exceedingly rare and usually signifies a marked immunodeficiency. Cryptococcosis in association with myasthenia gravis or thymoma has been previously documented in only very few cases in the literature.

CASE PRESENTATION

We reported a complicated case of severe cutaneous cryptococcosis in a 39-year-old Vietnamese male patient with myasthenia gravis on long-term immunosuppressive therapy. The patient presented with a five month history of recurrent and progressive skin lesions that later on progressed into cryptococcal meningitis.

CONCLUSION

Through this case, we aimed to emphasize the importance of including cutaneous cryptococcosis in the differential diagnosis of cutaneous lesions in patients on chronic immunosuppressive therapy. The cutaneous manifestations of cryptococcosis can be the first clue for a disseminated disease, which makes early recognition crucial and life-saving.

Disseminated cryptococcosis presenting as mediastinal and hilar lymphadenopathy in an immunocompetent patient

We herein report a rare case of disseminated cryptococcosis presenting as mediastinal and hilar lymphadenopathy in a young immunocompetent man. A previously healthy 26‐year‐old man presented with persistent headache and nonproductive cough. Chest computed tomography indicated mediastinal and hilar lymphadenopathy. Cryptococcal lymphadenitis and meningitis was confirmed by endobronchial ultrasound‐guided transbronchial needle aspiration and central spinal fluid examination, respectively. He received liposomal amphotericin B and flucytosine followed by fluconazole and finally improved.