Clinical features and radiological characteristics of pulmonary cryptococcosis

Pulmonary cryptococcosis in immunocompetent children presenting with chest pain: Three case reports

BACKGROUND

Cryptococcus is a systemic opportunistic pathogenic fungus that can cause infections in both immunocompromised and immunocompetent hosts, with diverse clinical manifestations, ranging from asymptomatic pulmonary lesions to disseminated central nervous system infections. The incidence of pulmonary cryptococcosis (PC) has rapidly increased in recent years, with an increasing proportion of non-human immunodeficiency virus-infected and immunocompetent patients making its diagnosis challenging. If not properly recognized, PC can lead to systemic dissemination and high mortality rates. Early diagnosis and treatment can improve the prognosis. This study summarizes the clinical features of three immunocompetent children with PC who presented with chest pain to raise clinicians' awareness of the disease and reduce mortality.

CASE SUMMARY

Three male pediatric patients in good health were hospitalized because of chest pain without cough or fever. Chest computed tomography (CT) revealed pleural-based nodules and consolidation with cavitation. A lung biopsy was performed in one case, and Cryptococcus was cultured from the pathological tissues. Cryptococcus was detected in the alveolar lavage fluid, and serum Cryptococcus capsular(C. capsular) polysaccharide antigen was positive in one case, and the other case was positive for serum C. capsular polysaccharide. All patients received oral fluconazole treatment. Follow-up chest CT scans after six months showed significant resolution of the lesions.

CONCLUSION

PC can also occur in immunocompetent children. When encountering children with chest pain only in the clinic, one should be vigilant about PC, promptly complete the relevant examinations, and avoid misdiagnosis.

Invasive fungal infections in patients with liver disease: immunological and clinical considerations for the intensive care unit

Patients with liver disease in the intensive care unit (ICU) face a unique susceptibility to infection due to the complex immune dysfunction resulting from hepatic failure. Bacterial infections are commonly present in these patients upon arrival to the hospital, often being the primary reason for ICU admission. In contrast, invasive fungal infections (IFIs) afflict a smaller percentage of patients and are usually discovered in the course of the ICU stay. IFI diagnosis in the ICU, particularly in patients with liver disease, is often delayed or overlooked, contributing to the extremely high ICU mortality associated with IFI in these patients despite the availability of effective (and largely safe) antifungal therapy. Thus, to improve outcomes, it is crucial for intensive care clinicians to be vigilant for IFIs in patients with liver disease. This review aims to contribute to the intensive care literature in this regard. We begin with an overview of normal antifungal immunity followed by a summary of how it may become compromised in the setting of hepatic dysfunction. Next, a general discussion of IFIs in liver disease is presented and then the three most relevant fungal pathogens, namely Candida, Aspergillus, and Cryptococcus, are individually examined. This review concludes by highlighting key knowledge and practice gaps that require attention by the scientific and clinical communities in the coming years.

Clinical imaging diagnosis of pulmonary cryptococcosis with different therapeutic responses

We aimed to differentiate and evaluate the clinical imaging features of pulmonary cryptococcosis with different therapeutic responses. The clinical imaging data of 70 patients with PC (complete response PC 37 cases and incomplete response PC 33 cases) were collected and compared to determine the independent risk factors for different therapeutic responses, and their diagnostic performances were verified by receiver operating characteristic curve analysis. Compared with complete response PC, incomplete response PC was more common with immunosuppression (10.8% vs. 45.5%, P = 0.001), intermediate progress (8.1% vs. 39.4%, P = 0.002), bilateral distribution (21.6% vs. 78.8%, P < 0.001), consolidation-interstitial pattern (10.8% vs. 42.4%, P = 0.003), pleural effusion (0 vs. 27.3%, P = 0.002) and mediastinal lymphadenopathy (0 vs. 24.2%, P = 0.005). Multivariate logistic regression showed that immunosuppression, intermediate progress, and bilateral distribution were independent risk factors, with low to moderate areas under curves (AUC, 0.656-0.786). Their combined performance was good with an AUC of 0.888. The diverse clinical imaging features can reflect the therapeutic response of PC. Immunosuppression, intermediate progress, and bilateral distribution were independent risk factors. Their combination can significantly improve diagnostic effects.

Dose Optimization of Fluconazole After Initial Treatment Failure in Pulmonary Cryptococcosis in an Obese Patient with Type 2 Diabetes and Cirrhosis: A Case Report

Background

Pulmonary cryptococcosis is a fungal infection of the lungs, particularly challenging to treat in patients with multiple comorbidities such as obesity, type 2 diabetes, and cirrhosis. Fluconazole is a first-line medication for the treatment of pulmonary cryptococcosis, but currently there is a lack of clinical medication experience in obese patients with multiple comorbidities, especially in dose adjustment after treatment failure.

Case Introduction

This case report describes the experience of fluconazole in the treatment of pulmonary cryptococcal infection in a 45-year-old Chinese male with obesity, type 2 diabetes, and cirrhosis. The patient had a history of antifungal therapy for two weeks before admission, but the cough and hemoptysis were not improved. The treatment failed. After admission, it was recommended to use a conventional dose of fluconazole as an antifungal regimen according to the guidelines. However, the treatment effect was still unsatisfactory, due to the patients' cough, hemoptysis, and fever symptoms were not relieved. During this period, it was newly found that the patient had cirrhosis and type 2 diabetes and had not previously controlled blood glucose. Considering the above situation, combined with the pharmacokinetic characteristics of fluconazole and the patient's weight reaching 113 kg, the team readjusted the fluconazole medication regimen, and ultimately, the pulmonary infection improved without significant adverse reactions.

Results

We found that it was more suitable for patients with obesity to calculate the dose of fluconazole by the lean weight. By estimation, the patient was finally given a loading dose of 800 mg fluconazole, and his condition improved significantly. After two weeks of medication, it was adjusted to a maintenance dose of 600 mg until the pulmonary infection in the patient disappeared.

Conclusion

This case suggests that fluconazole antifungal therapy for pulmonary cryptococcal infection should fully consider the risk of comorbidities in patients. If necessary, medication dosage can be adjusted according to weight, and it is recommended to use lean bodyweight for evaluation and optimization. In addition, close attention should be paid to liver and kidney function.

Pulmonary cryptococcosis masquerading as lung metastasis in gynecologic cancers: Two case reports

RATIONALE

Pulmonary cryptococcal infections occur mainly in immunocompromised individuals, such as those with malignancies. Preoperative diagnosis of pulmonary cryptococcosis (PC) can be challenging for both clinicians and radiologists because of nonspecific clinical manifestations and variable radiologic features, as it is easily misdiagnosed as metastatic lung cancer.

PATIENT CONCERNS

In case 1, a 76-year-old woman with a history of cervical cancer presented with lung nodules detected on chest computed tomography (CT) 13 months after completing concurrent chemoradiotherapy. In case 2, a 56-year-old woman with a history of ovarian cancer presented with pulmonary nodules on chest CT 19 months after completing chemotherapy. Both patients were clinically asymptomatic, and tumor markers were not elevated.

DIAGNOSES

In case 1, chest CT revealed multiple enhanced nodules with lobulated margins in the left lower lobe, and positron emission tomography (PET)-CT showed uptake in the nodule with a standardized uptake value of 3.7. In case 2, chest CT revealed several nodules in the right upper lobe abutting the right major fissure, and PET-CT revealed fluorodeoxyglucose uptake in the nodules. Pathology revealed granulomatous inflammation with cryptococcal infection, and mucicarmine and periodic acid-Schiff staining confirmed cryptococcal infection in both cases.

INTERVENTIONS

Presumptive diagnoses of lung metastases were made in both cases and thoracoscopic lobectomy was performed. Postoperatively, the patients received antifungal therapy with fluconazole.

OUTCOMES

PC was differentially diagnosed and effectively managed. The patients remained disease-free for both PC and gynecological cancers during subsequent follow-ups.

LESSONS

Recognition that PC can mimic lung metastasis is important for managing gynecological cancers. PC should be considered in the differential diagnosis when single or multiple nodules are detected on chest radiography without elevation of tumor markers in patients with gynecological cancer.

A CT-based radiomics integrated model for discriminating pulmonary cryptococcosis granuloma from lung adenocarcinoma-a diagnostic test

Background

Chest computed tomography (CT) is a critical tool in the diagnosis of pulmonary cryptococcosis as approximately 30% of normal immunity individuals may not exhibit any significant symptoms or laboratory findings. Pulmonary cryptococcosis granuloma and lung adenocarcinoma can appear similar on noncontrast chest CT. This study evaluates the use of an integrated model that was developed based on radiomic features combined with demographic and radiological features to differentiate pulmonary cryptococcosis nodules from lung adenocarcinomas.

Methods

Preoperative chest CT images for 215 patients with solid pulmonary nodules with histopathologically confirmed lung adenocarcinoma and cryptococcosis infection were collected from two clinical centers (108 cases in the training set and 107 cases in the test set divided by the different hospitals). Radiomics models were constructed based on nodular lesion volume (LV), 5-mm extended lesion volume (ELV), and perilesion volume (PLV). A demoradiological model was constructed using logistic regression based on demographic information (age, sex) and 12 radiological features (location, number, shape and specific imaging signs). Both models were used to build an integrated model, the performance of which was assessed using the test set. A junior and a senior radiologist evaluated the nodules. Receiver operating characteristic (ROC) curve analysis was conducted, and areas under the curve (AUCs), sensitivity (SEN), and specificity (SPE) of the models were calculated and compared.

Results

Among the radiomics models, AUCs of the LV, ELV, and PLV were 0.558, 0.757, and 0.470, respectively. Age, lesion number, and lobular sign were identified as independent discriminative features providing an AUC of 0.77 in the demoradiological model (SEN 0.815, SPE 0.642). The integrated model achieved the highest AUC of 0.801 (SEN 0.759, SPE 0.755), which was significantly higher than that obtained by a junior radiologist (AUC =0.689, P=0.024) but showed no significant difference from that of the senior radiologist (AUC =0.784, P=0.388).

Conclusions

An integrated model with radiomics and demoradiological features improves discrimination of cryptococcosis granulomas from solid adenocarcinomas on noncontrast CT. This model may be an effective strategy for machine complementation to discrimination by radiologists, and whole-lung automated recognition methods might dominate in the future.

Prostatitis as initial manifestation of Chlamydia psittaci pneumonia diagnosed by metagenome next-generation sequencing: A case report

Chlamydia psittaci (C. psittaci) pneumonia is a zoonotic infectious disease caused by C. psittaci, which is often underdiagnosed. The application of metagenomic next-generation sequencing (mNGS) provides an unbiased method for the detection of unknown pathogens. A 46-year-old man received empirical treatment with piperacillin-tazobactam and moxifloxacin after an initial diagnosis of prostatitis and pneumonia. However, he experienced recurrent symptoms and a cough, and a chest computed tomography (CT) showed aggravated pulmonary inflammation. Upon further questioning, the patient recalled a history of contact with pigeons, and a bronchoscope alveolar lavage fluid analysis with mNGS suggested C. psittaci infection. Following treatment with doxycycline, the patient's symptoms were rapidly alleviated, and chest CT showed pulmonary lesions absorption. The patient was followed up for 1 month without any discomfort. This case highlights that initial manifestations of C. psittaci pneumonia may present with atypical symptoms such as prostatitis. Furthermore, mNGS can be a useful tool for the detection of rare or unknown pathogens such as C. psittaci.

Metagenomic next-generation sequencing contributes to the diagnosis of mixed pulmonary infection: a case report

BACKGROUND

Pulmonary cryptococcosis (PC) and mixed pulmonary infection are difficult to be diagnosed due to the non-specificity and their overlapping clinical manifestations. In terms of the clinical diagnosis of PC and mixed pulmonary infection, conventional tests have limitations such as a long detection period, a limited range of pathogens, and low sensitivity. Metagenomics next-generation sequencing (mNGS) is a nascent and powerful method that can detect pathogens without culture, to diagnose known and unexplained infections in reduced time.

CASE PRESENTATION

A 43-year-old female was admitted to the hospital after suffering from a cough for one month. At the time of admission, a contrast-enhanced chest CT revealed multiple nodules and plaques in her right lung, as well as the formation of cavities. The blood routine assays showed evidently increased white blood cell count (mainly neutrophils), CRP, and ESR, which suggested she was in the infection phase. The serum CrAg-LFA test showed a positive result. Initially, she was diagnosed with an unexplained pulmonary infection. Bronchoalveolar lavage fluid (BALF) samples were collected for microbial culture, immunological tests and the mNGS. Microbial culture and immunological tests were all negative, while mNGS detected Corynebacterium striatum, Pseudomonas aeruginosa, Streptococcus pneumoniae, and Cryptococcus neoformans. The diagnosis was revised to PC and bacterial pneumonia. Lung infection lesions were healed after she received targeted anti-infection therapy with mezlocillin and fluconazole. In a follow-up after 2 months, the patient's symptoms vanished.

CONCLUSIONS

Here, we demonstrated that mNGS was capable of accurately distinguishing Cryptococcus from M. tuberculosis in pulmonary infection, and notably mNGS was capable of swiftly and precisely detecting pathogens in mixed bacterial and fungal pulmonary infection. Furthermore, the results of mNGS also have the potential to adjust anti-infective therapies.

Clinical Diagnosis, Treatment, and Laboratory Detection of 50 Cases of Pulmonary Cryptococcosis

Objective

This study retrospectively analyzed the clinical diagnosis, treatment process, and laboratory test data of patients with pulmonary cryptococcosis to improve the understanding and diagnosis and treatment ability of the disease.

Methods

Patients with pulmonary cryptococcosis diagnosed in the First Affiliated Hospital of Dalian Medical University from October 2003 to July 2021 were selected, and their medical records were consulted. The general data, clinical manifestations, laboratory examinations, imaging characteristics, diagnosis, and treatment methods were studied. The software SPSS 22 was used for statistical analysis.

Results

A total of 50 patients with pulmonary cryptococcosis were included in the study. The ratio of male to female was 1 : 1. The average age was 53.56 ± 11.99 years with a range of 27-82 years. Grouping the patients by age, with 10 years as an age group, we found that 40-60 years was the high-incidence age group. Two patients (4%) had a history of bird contact, and 18 patients (36%) had at least one underlying conditions. Hypertension and cough were the most common underlying condition and clinical manifestation, respectively. The main admission diagnoses were lung shadow (19/50, 38%) and chest/lung mass (15/50, 30%). In the imaging findings, the most common type of lesions was nodule/nodule shadow (29/69, 42.03%). Lesion distribution in the lower lobe, single lobe, and right lung was more frequent than that in the upper lobe, multilobes, and left lung, respectively. Burr sign (12/43, 27.91%) was the most common concomitant sign. Pulmonary ventilatory defect was found in 7 cases. Laboratory test results were largely nonspecific. The pathological examination showed granuloma, with 47 cases (94%) confirmed by postoperative biopsy. Two cases (4%) were confirmed by serology. One case (2%) was diagnosed with Cryptococcus smear. 43 cases (86%) were treated with simple surgical resection, 6 cases (12%) were treated with antifungal drugs, and 1 case (2%) was transferred to another hospital for suspicion of pulmonary tuberculosis.

Conclusions

Pulmonary cryptococcosis is more common in the middle-aged and elderly, and the clinical specificity is low. It can occur in people with normal or impaired immune function. The main clinical and imaging manifestation is cough and pulmonary nodules, which are very easy 5to be misdiagnosed. Surgical resection is the primary treatment.

Pulmonary CT scans of white rabbits using the selective photon shield technique of the third-generation dual-source CT

This study aims to optimise the protocol for the low-dose pulmonary computed tomography (CT) scanning of infants by studying the effects of the selective photon shield (SPS) technique of the third-generation dual-source CT (DSCT) on the image quality and radiation dose of a chest CT in white rabbits under different tube currents. Twelve white rabbits of a similar weight to an infant were selected and randomly divided into an experimental group and a control group. The experimental groups (A1-A5) were scanned at low dose by the third-generation DSCT using SPS under different tube current × time (60, 50, 40, 30, and 20 mAs). The control group (B) was scanned under a conventional tube voltage (100 kV) and current × time (20 mAs). Advanced model iterative reconstruction at strength three was used for the objective and subjective evaluation of the image quality and radiation dose of the lung and mediastinal windows. With the standard deviation of the air in the trachea as image noise, the signal-to-noise ratio (SNR), contrast-to-noise ratio, and CT values of each site were evaluated. Radiation doses were compared using the volume CT dose index, dose length product, and effective dose. The differences in subjective image quality between groups A2 and B were not statistically significant (P= 0.34). The differences in the SNRs of the lung and mediastinal windows between groups A2 and B were not statistically significant (P> 0.05). The radiation dose of group A2 was 83.2% lower than that of group B. The SPS of the third-generation DSCT under 50 mAs might be applied in the pulmonary CT examination of infants.

Computed tomography-based radiomics for identifying pulmonary cryptococcosis mimicking lung cancer

BACKGROUND

Pulmonary cryptococcosis (PC) is an invasive pulmonary fungal disease, and nodule/mass-type PC may mimic lung cancer (LC) in imaging appearance. Thus, an accurate diagnosis of nodule/mass-type PC is beneficial for appropriate management. However, the differentiation of nodule/mass-type PC from LC through computed tomography (CT) is still challenging.

PURPOSE

To develop and externally test a CT-based radiomics model for differentiating nodule/mass-type PC from LC.

METHODS

In this retrospective study, patients with nodule/mass-type PC or LC who underwent non-enhanced chest CT were included: institution 1 was for the training set, and institutions 2 and 3 were for the external test set. Large quantities of radiomics features were extracted. The radiomics score (Rad-score) was calculated using the linear discriminant analysis, and a subsequent 5-fold cross-validation was performed. A combined model was developed by incorporating Rad-score and clinical factors. Finally, the models were tested with an external test set and compared using the area under the receiver operating characteristic curve (AUC).

RESULTS

A total of 168 patients (45 with PC and 123 with LC) were in the training set, and 72 (36 with PC and 36 with LC) were in the external test set. Of the 81 patients with PC, 30 were immunocompromised (37%). Rad-score, comprised of 18 features, had an AUC of 0.844 after 5-fold cross-validation, which was lower than that (AUC = 0.943, P = 0.003) of the combined model integrating Rad-score, age, lobulation, pleural retraction, and patches. In the external test set, Rad-score and the combined model obtained good predictive performance (AUC = 0.824 for Rad-score, and 0.869 for the combined model). Moreover, the combined model outperformed the clinical model in the cross-validation and external test (0.943 vs. 0.810, P <0.001; 0.869 vs. 0.769, P = 0.011).

CONCLUSIONS

The proposed combined model exhibits a good differential diagnostic performance between nodule/mass-type PC and LC. The CT-based radiomics analysis has the potential to serve as an effective tool for the differentiation of nodule/mass-type PC from LC in clinical practice. This article is protected by copyright. All rights reserved.

Development and Validation of a Radiomics Nomogram for Differentiating Pulmonary Cryptococcosis and Lung Adenocarcinoma in Solitary Pulmonary Solid Nodule

Objective

To establish a CT-based radiomics nomogram model for classifying pulmonary cryptococcosis (PC) and lung adenocarcinoma (LAC) in patients with a solitary pulmonary solid nodule (SPSN) and assess its differentiation ability.

Materials and Methods

A total of 213 patients with PC and 213 cases of LAC (matched based on age and gender) were recruited into this retrospective research with their clinical characteristics and radiological features. High-dimensional radiomics features were acquired from each mask delineated by radiologists manually. We adopted the max-relevance and min-redundancy (mRMR) approach to filter the redundant features and retained the relevant features at first. Then, we used the least absolute shrinkage and operator (LASSO) algorithms as an analysis tool to calculate the coefficients of features and remove the low-weight features. After multivariable logistic regression analysis, a radiomics nomogram model was constructed with clinical characteristics, radiological signs, and radiomics score. We calculated the performance assessment parameters, such as sensitivity, specificity, accuracy, negative predictive value (NPV), and positive predictive value (PPV), in various models. The receiver operating characteristic (ROC) curve analysis and the decision curve analysis (DCA) were drawn to visualize the diagnostic ability and the clinical benefit.

Results

We extracted 1,130 radiomics features from each CT image. The 24 most significant radiomics features in distinguishing PC and LAC were retained, and the radiomics signature was constructed through a three-step feature selection process. Three factors-maximum diameter, lobulation, and pleural retraction-were still statistically significant in multivariate analysis and incorporated into a combined model with radiomics signature to develop the predictive nomogram, which showed excellent classification ability. The area under curve (AUC) yielded 0.91 (sensitivity, 80%; specificity, 83%; accuracy, 82%; NPV, 80%; PPV, 83%) and 0.89 (sensitivity, 81%; specificity, 83%; accuracy, 82%; NPV, 81%; PPV, 82%) in training and test cohorts, respectively. The net reclassification indexes (NRIs) were greater than zero (p < 0.05). The Delong test showed a significant difference (p < 0.0001) between the AUCs from the clinical model and the nomogram.

Conclusions

The radiomics technology can preoperatively differentiate PC and lung adenocarcinoma. The nomogram-integrated CT findings and radiomics feature can provide more clinical benefits in solitary pulmonary solid nodule diagnosis.

Clinical and Computed Tomography (CT) Characteristics of Pulmonary Nodules Caused by Cryptococcal Infection

Purpose

To investigate the clinical and computed tomography (CT) characteristics of pulmonary nodules caused by cryptococcal infection and gain a greater insight and understanding that will reduce misdiagnosis.

Materials and Methods

A total of 47 patients with confirmed pulmonary cryptococcosis (PC) manifested as nodules were retrospectively enrolled from January 2013 to December 2020. The clinical and CT data of patients with single and multiple nodules were analyzed and compared with emphasis on exploring the characteristics of the solitary ones.

Results

Among the 47 patients, single and multiple nodules were detected in 25 (53.2%) and 22 (46.8%) patients, respectively, with similar clinical characteristics. The diameter of solitary nodules was smaller than that of the largest ones of the multiple nodules (P = 0.000). Compared with multiple nodules, less solitary nodules were located in the subpleural zone (P = 0.031) and had a cavity or vacuole (P = 0.049). Regarding the solitary nodules, 22 (88.0%) and 3 (12.0%) were solid and subsolid, respectively. Eighteen (81.8%) solid solitary nodules exhibited either one of air bronchogram or vacuole, satellite lesions, and halo sign. Twenty-three (92.0%) of 25 patients with solitary nodules had follow-up CT data, and most of them had no changes (12, 52.1%) or increased in size and/or density (8, 34.8%), but only a few (3, 13.0%) decreased with or without anti-inflammatory therapy.

Conclusion

The clinical characteristics of patients with solitary and multiple nodules caused by PC are similar. The solitary nodules are smaller, more scattered, but less necrotic than multiple ones. For solitary nodules with air bronchogram or vacuole, satellite lesions, or halo sign, PC should be considered as one of the differential diagnosis.

Clinical features of cryptococcosis in patients with different immune statuses: a multicenter study in Jiangsu Province-China

Background

Current guidelines support different management of cryptococcosis between severely immunodeficient and immunocompetent populations. However, few studies have focused on cryptococcosis patients with mild-to-moderate immunodeficiency. We performed this study to determine the clinical features of pulmonary (PC) and extrapulmonary cryptococcosis (EPC) and compared them among populations with different immune statuses to support appropriate clinical management of this public health threat.

Methods

All cases were reported by 14 tertiary teaching hospitals in Jiangsu Province, China from January 2013 to December 2018. The trends in incidence, demographic data, medical history, clinical symptoms, laboratory test indicators, imaging characteristics and diagnostic method of these patients were then stratified by immune status, namely immunocompetent (IC, patients with no recognized underlying disease or those with an underlying disease that does not influence immunity, such as hypertension), mild-to-moderate immunodeficiency (MID, patients with diabetes mellitus, end-stage liver or kidney disease, autoimmune diseases treated with low-dose glucocorticoid therapy, and cancer treated with chemotherapy) and severe immunodeficiency (SID, patients with acquired immunodeficiency syndrome, haematologic malignancies, solid organ transplantation or haematologic stem cell transplantation, idiopathic CD4 lymphocytosis, agranulocytosis, aggressive glucocorticoid or immunosuppressive therapy and other conditions or treatments that result in severe immunosuppression).

Results

The clinical data of 255 cryptococcosis patients were collected. In total, 66.3% of patients (169) were IC, 16.9% (43) had MID, and 16.9% (43) had SID. 10.1% of the patients (17) with IC were EPC, 18.6% of the patients (8) with MID were EPC, and 74.4% of patients (32) were EPC (IC/MID vs. SID, p < 0.001). Fever was more common in the SID group than in the IC and MID groups (69.8% vs. 14.8% vs. 37.2%, p < 0.001). Of chest CT scan, most lesions were distributed under the pleura (72.7%), presenting as nodules/lumps (90.3%) or consolidations (10.7%). Pleural effusion was more common in SID group compared to IC group (33.3% vs. 2.4%, p < 0.001). Positivity rate on the serum capsular polysaccharide antigen detection (CrAg) test was higher in the SID group than in the other two groups [100.0% vs. 84.4% (MID) vs. 78.2% (IC), p = 0.013]. Positivity rate on the serum CrAg test was also higher in cryptococcal meningitis patients than in PC patients (100.0% vs. 79.5%, p = 0.015).

Conclusions

The clinical presentation of MID patients is intermediate between SID and IC patients and is similar to that of IC patients. The serum CrAg test is more sensitive for the identification of SID or EPC patients.

The effects of specialized emergency and intensive nursing team on arterial blood gas and pulmonary function in pulmonary infection with respiratory failure

OBJECTIVE

To investigate effects of specialized emergency and intensive nursing team on arterial blood gas and pulmonary function in pulmonary infected patients with respiratory failure.

METHODS

126 patients with pulmonary infection and respiratory failure admitted to our hospital were chosen and randomly divided into observation group and control group, with 63 cases in each group. The control-group received specialized routine nursing care, and the observation-group was treated with the emergency and intensive nursing care. Subsequently, the arterial blood gas, pulmonary function, inflammatory biomarkers, complication rate, recovery course and nursing satisfaction between the two groups were compared accordingly.

RESULTS

After nursing care, the arterial blood gas and pulmonary function indexes of the two groups were remarkably improved than before, and the improvement in observation-group was superior to that in control-group (P<0.05); The inflammatory indicators of hs-CRP and PCT in two groups decreased substantially than before, and observation-group had remarkably lower indicators than that of the control-group (P<0.05); The incidence of complications in observation-group was 4.76%, significantly lower than 19.05% in control-group (P<0.05); The objects in observation-group spent exactly shorter time on ventilator than whom in control-group, and the difference was statistically significant (P<0.05); The observation-group had critically shorter length of hospital stay than those in control-group (P<0.05). The satisfaction of the observation-group with nursing care was 93.65%, which was dramatically higher than 73.02% in control-group (P<0.05).

CONCLUSIONS

For pulmonary infection and respiratory failure, the nursing intervention carried by the specialized emergency and intensive nursing team can remarkably improve the arterial blood gas and pulmonary function, reduce the patients' inflammatory indicators and incidence of complications. The application of the nursing team can reduce the time on ventilator and length of hospital stay, and improve patients' satisfaction with nursing care.

Comprehensive Analysis and Risk Identification of Pulmonary Cryptococcosis in Non-HIV Patients

Pulmonary cryptococcosis in the non-human immunodeficiency virus-infected population is uncommon. We aimed to explore the relevance between clinical presentations, radiological findings, and comorbidities and identify the outcome predictors. A total of 321 patients at Taichung Veterans General Hospital between 2005 and 2019 were included; of them, 204 (63.6%) had at least one comorbidity, while 67 (20.9%) had two or more. The most common comorbidities were diabetes mellitus (27.4%), malignant solid tumor (19.6%), autoimmune disease (15.6%), and chronic kidney disease (8.4%). Patients experiencing comorbidity, particularly those with multiple comorbidities, had a higher multilobar and extrapulmonary involvement, which could explain these patients being more symptomatic. In the overall population, extrapulmonary involvement independently predicted disease recurrence and death. Amongst patients with isolated pulmonary cryptococcosis, age, cryptococcal antigen (CrAg) titer in blood, and comorbidities not only predicted the extent of disease, but also its outcome. Of note, patients simultaneously with age ≥ 65 years, CrAg test ≥ 1:128, and multiple comorbidities had the lowest disease control of antifungal treatment (76.9%) and the highest rate of disease recurrence or death from any cause (40.0%). In conclusion, approximately two-thirds of patients had at least one underlying comorbidity. In addition to extrapulmonary involvement, old age, high CrAg titer in blood, and multiple comorbidities could act as risk factors for predicting the extent of disease and outcome.

Infectious lung masses misdiagnosed as metastatic rhabdomyosarcoma: Two case reports

Rhabdomyosarcoma (RMS) with regional lymph node involvement has a high rate of distant metastases. Lung is the most common site, accounting for 70% of all metastases. The differential diagnosis of lung lesions due to an infectious aetiology versus metastases is usually evaluated by computed tomography (CT) or magnetic resonance imaging. However, it is rare for patients of RMS to present with infectious nodules or masses in the lung during follow-up. More importantly, infections can mimic the imaging characteristics of metastatic RMS in CT. We report two such cases where children diagnosed with head and neck embryonal RMS with lymph node metastasis, presented with pulmonary masses 0.5 and 4 years after end of treatment, without the typical signs and symptoms suggestive of an infection. Chest CT suggested a provisional diagnosis of metastases and biopsies confirmed infectious aetiology (Mycobacterium tuberculosis, Cryptococcus).

Comparison of cryptococcal meningitis in HIV-negative patients with and without lung infections

Objective

To investigate the clinical features and outcomes of cryptococcal meningitis (CM) in HIV-negative patients with and without lung infections.

Methods

We retrospectively reviewed the medical records of HIV-negative patients with CM admitted to two university hospitals in Southwest China over the past 5 years.

Results

Seventy-one patients were included, of whom 35 (49.3%) had lung disease. Compared with patients without lung infection, CM patients with lung infection tended to be male and younger (≤30 years), experienced more fever, less vomiting and fewer central nervous system symptoms; more often had low white blood cell (WBC) counts (<20 × 10⁶/L), and fewer often had ethmoid sinusitis, maxillary sinusitis, paranasal sinusitis, and otitis media. Cryptococcus neoformans isolates from these patients were sensitive to itraconazole, voriconazole, fluconazole, and amphotericin B but resistant to flucytosine. CM patients with lung infection had higher mortality at discharge compared with patients without lung infection (8.6% vs. 0%). Multivariable analyses showed that a WBC count <20 × 10⁶/L was significantly associated with poor treatment outcome (odds ratio 0.01, 95% confidence interval 0–0.83).

Conclusion

HIV-negative CM patients with lung infections tended to be male and younger. Fever, fewer central nervous system symptoms, and WBC counts <20 × 10⁶/L were characteristic of this patient group.

Pulmonary cryptococcosis coexisting with central type lung cancer in an immuocompetent patient: a case report and literature review

Background

Pulmonary Cryptococcosis is a common fungal infection mainly caused by Cryptococcus neoformans/C.gattii species in immunocompromised patients. Cases of pulmonary cryptococcosis in patients with normal immune function are increasingly common in China. Clinical and radiographic features of pulmonary cryptococcosis are various and without obvious characteristics, so it is often misdiagnosed as pulmonary metastatic tumor or tuberculosis. When coexisting with malignant lung tumors, it was more difficult to differentiate from metastatic lung cancer, although the coexistence of pulmonary cryptococcosis and central type lung cancer is rare. Reviewing the imaging manifestations and diagnosis of the case and the relevant literature will contribute to recognition of the disease and a decrease in misdiagnoses.

Case presentation

A 72-year-old immunocompetent Han Chinese man had repeated dry cough for more than half a year. CT examination of chest showed an irregular mass at the left hilum of the lung, and two small nodules in the right lung, which were considered as the left central lung cancer with right lung metastasis. However, the patient was diagnosed with pulmonary cryptococcosis coexisting with central type lung cancer based on the results of laboratory examination, percutaneous lung biopsy, fiberoptic bronchoscopy, and surgical pathology. The patient underwent surgical resection of the left central type lung cancer and was placed on fluconazole treatment after a positive diagnosis was made. Five years after the lung cancer surgery, the patient had a recurrence, but the pulmonary cryptococcus nodule disappeared.

Conclusion

Our case shows that CT findings of central type lung cancer with multiple pulmonary nodules are not necessarily metastases, but may be coexisting pulmonary cryptococcosis. CT images of cryptococcosis of the lung were diverse and have no obvious characteristics, so it was very difficult to distinguish from metastatic tumors. CT-guided percutaneous lung biopsy was a simple and efficient method for identification.

Pulmonary Cryptococcosis: comparison of Cryptococcal antigen detection and radiography in Immunocompetent and Immunocompromised patients

Background

We compared the cryptococcal antigen detection and imaging findings between immunocompetent and immunocompromised patients in whom pulmonary cryptococcosis had been diagnosed. The aim of our study was to determine whether the patient’s immune status and radiography affect the detection of cryptococcal antigen.

Methods

According to whether they took immunosuppressive drugs or not, seventy and eight adult patients with pulmonary cryptococcosis were divided into two groups: the immunocompetent group and the immunocompromised group. According to the detection of CrAg, each group was divided into the CrAg+ group and the CrAg- group. Then, clinical records, laboratory examinations and computed tomography findings were collected and analyzed.

Results

No difference was found in baseline characteristics, clinical symptoms, and laboratory investigations. By comparing CrAg detection in these two groups, it was found that the number of CrAg+ cases in the immunocompetent group was more than that in the immunocompromised group. And in the immunocompetent group, diffuse lesions were more common in CrAg+ group and limited lesions were more frequently observed in CrAg- group.

Conclusions

The patient’s immune status and radiography would affect the detection of cryptococcal antigen. And serum CrAg could be a useful tool for the diagnosis of pulmonary cryptococcosis in immunocompetent patients with extensive lung involvement.

Pulmonary Cryptococcosis in a Nurse Initially Suspected of Having Pulmonary Tuberculosis

Patient: Female, 34-year-old

Final Diagnosis: Pulmonary cryptococcosis

Symptoms: None

Medication: —

Clinical Procedure: Bronchoscopy

Specialty: Infectious Diseases

Pulmonary cryptococcosis complicating interstitial lung disease in a patient with systemic lupus erythematosus

We report a case of primary pulmonary cryptococcosis in a 59-year-old female patient with a history of systemic lupus erythematosus, interstitial lung disease and glaucoma. She presented with a cough, severe fatigue, unintentional weight loss, shortness of breath (increase in home oxygen use from baseline) and pleuritic chest pain of 2 months duration. During these 2 months, her symptoms had worsened despite multiple hospital visits, empirical antibiotics and empirical increase of her steroid dosage. Cytopathology of the bronchoalveolar lavage fluid showed yeast cells with narrow-based budding and grew Cryptococcus neoformans on fungal culture. She was treated with oral fluconazole 400 mg/day for 6 months with an improvement in cough, decrease in shortness of breath (return to baseline oxygen use) and resolution of pleuritic chest pain.