Pulmonary cryptococcosis characteristics in immunocompetent patients-A 20-year clinical retrospective analysis in China

Unmasking the Unusual: Cryptococcal Pericarditis in a Patient with Liver Failure - a Rare Occurrence

BACKGROUND Cryptococcosis is an invasive fungal infection caused by Cryptococcus species complex. C. neoformans is one of the pathogenic species within the genus. C. neoformans infections often present as an opportunistic infection in severely immunocompromised individuals. Infection of the pericardium in the setting of liver failure is uncommon. We present a case of cryptococcal pericarditis in a patient with liver failure. CASE REPORT A 47-year-old man with a past medical history of psoriatic arthritis, and alcohol use disorder presented to the emergency department with a 2-week history of progressively worsening generalized weakness, malaise, and yellowish skin changes. Physical examination revealed scleral icterus, jaundiced skin, and ascites. Initial laboratory workup revealed thrombocytopenia, transaminitis (aspartate transaminase (AST) level of 502 IU/L, alanine transaminase (ALT) level of 82 IU/L), hyperbilirubinemia (total bilirubin of 15.7 mg/dL), International Nationalized Ratio (INR) of 3.6, and lactic acidosis (lactic acid of 11.7 mmol/L). The patient developed encephalopathy and acute hypoxic respiratory failure requiring intubation. A bedside point-of-care cardiac ultrasound, performed following intubation, revealed a pericardial effusion without signs of tamponade. This finding was later confirmed by a formal transthoracic echocardiogram. Percutaneous pericardiocentesis was performed, and the pericardial fluid culture revealed the presence of C. neoformans. Human immunodeficiency virus (HIV) tests were negative. The patient received antifungal therapy. Due to his poor prognosis, he was transitioned to comfort care and eventually died. CONCLUSIONS This case report describes an unusual presentation of acute liver failure complicated by cryptococcal pericarditis, emphasizing the importance of considering atypical fungal infections in such patients.

Macrophages-derived exo-miR-4449 induced by Cryptococcus affects HUVEC permeability and promotes pyroptosis in BEAS-2B via the HIC1 pathway

Macrophages have recently been discovered to assume a significant role in the progression of cryptococcosis. However, the potential involvement of macrophage-derived exosomes in the pathogenesis of cryptococcosis remains uncertain. In this study, we investigated the changes of microRNAs in macrophage exosomes (exo-miRNAs) in cryptococcal infections and the role of markedly altered exo-miRNAs in the modulation of Human Umbilical Vein Endothelial Cells (HUVEC) permeability and ROS accumulation and pyroptosis in Human Bronchial Epithelioid Cells (BEAS-2B). Techniques such as microarray analysis and real-time quantitative PCR were used to detect different exo-miRNAs and to screen for the most highly expressed exo-miRNAs. Then its mimics were transfected into HUVEC to study its effect on the monolayer permeability of HUVEC. Finally, the relationship between this exo-miRNAs and the ROS accumulation and pyroptosis was verified by bioinformatics analysis. The results showed that five exo-miRNAs were overexpressed and two exo-miRNAs were reduced, among which, exo-miR-4449 was expressed at the highest level. Exo-miR-4449 could be internalized by HUVEC and enhanced its monolayer permeability. Moreover, exo-miR-4449 was found to promote ROS accumulation and pyroptosis in BEAS-2B through HIC1 pathway. Thus, exo-miR-4449 plays an important role in the pathogenesis of cryptococcosis and holds promise as a significant biomarker for treatment.

Cryptococcosis in Southern China: Insights from a Six-Year Retrospective Study in Eastern Guangdong

Objective

Cryptococcosis is a fatal infection that can affect both immunocompetent and immunocompromised patients, and it is little understood in China's various regions. This research aimed to look at the epidemiology, risk factors, and antifungal susceptibility pattern of Cryptococcus neoformans in eastern Guangdong, China.

Methods

A six-year (2016-2022) retrospective study was conducted at Meizhou People's Hospital, China. Demographical, clinical, and laboratory data of cryptococcal patients were collected from hospital records and statistically analyzed using the chi-square and ANOVA tests.

Results

Overall, 170 cryptococcal infections were recorded, of which meningitis accounted for 78 (45.88%), cryptococcemia for 50 (29.41%), and pneumonia for 42 (24.7%). The number of cases increased 8-fold during the study duration. The median age of patients was 58 years (Inter quartile range: 47-66), and the high proportion of cases was from the male population (n = 121, 71.17%). The underlying diseases were identified only in 60 (35.29%) patients, of which 26 (15.29%) were severely immunocompromised, and 26 (15.29%) others were mildly immunocompromised. A statistically significant difference was reported for chronic renal failure, and anemia (p < 0.05) persisted in cases of three infection types. A high number of non-wild type (NWT) isolates were found against amphotericin B (n=13/145, 8.96%), followed by itraconazole (n=7/136, 5.15%) and voriconazole (n=4/158, 2.53%). Only six isolates (3.79%) were multidrug-resistant, four of which were from cryptococcemia patients. Compared to meningitis and pneumonia, cryptococcemia revealed a higher percentage of NWT isolates (p < 0.05).

Conclusion

In high-risk populations, cryptococcal infections require ongoing monitoring and management.

Lesion size as a prognostic factor in the antifungal treatment of pulmonary cryptococcosis: a retrospective study with chest CT pictorial review of 2-year follow up

BACKGROUND

Pulmonary cryptococcosis (PC) is a fungal infection that can have a variable prognosis depending on several factors. The objective of this study was to analyse the characteristics of pulmonary lesions and identify prognostic factors in patients with PC who were human immunodeficiency virus (HIV) -negative and underwent antifungal treatment.

METHODS

The study enrolled patients diagnosed with PC who were negative for HIV. Symptoms, CT characteristics of pulmonary lesions, serum cryptococcal capsular antigen (CrAg) titre, underlying diseases, and duration of antifungal treatment were evaluated over a 2-year follow-up.

RESULTS

A total of 63 patients (40 men and 23 women) with a mean age of 50.4 years were included. Half of the patients (50.8%) were asymptomatic, and the most common symptoms were cough (44.4%), expectoration (27.0%), and fever (17.5%). Pulmonary lesions were mainly present in the peripheral and lower lobes of the lung, with 35 cases classified as nodular-type lesions and 28 cases classified as mass-type lesions. At the first, third, sixth, 12th, and 24th-month follow-ups, the median proportion of residual pulmonary lesions were 59.6%, 29.9%, 12.2%, 9.6%, and 0.0%, respectively. During antifungal treatment, the lesions of 33 patients achieved complete response, while the remaining 30 patients did not. Compared with the non-CR group, the CR group had a lower baseline serum CrAg titre (median, 1:20 vs 1:80, P < 0.01), smaller pulmonary lesion size (median area, 1.6 cm² vs 6.3 cm², P < 0.01), lower Hounsfield-units (HU) radiodensity (median, - 60.0 HU vs - 28.5 HU, P < 0.05), more nodular-type lesions (72.7% vs 36.7%, P < 0.01), and fewer air-bronchogram signs (18.2% vs 43.3%, P < 0.05). Multivariate logistic regression analysis showed that a larger lesion size on chest CT scans was associated with a lower likelihood of achieving complete response [OR: 0.89; 95% CI (0.81-0.97); P < 0.05].

CONCLUSIONS

PC was more commonly observed in HIV-negative men, and chest CT scans mostly revealed nodular-type lesions. After antifungal treatment, patients with smaller lesions had a better prognosis.

Clinical utility of cryptococcal antigen detection in transthoracic needle aspirate by lateral flow assay for diagnosing non-HIV pulmonary cryptococcosis: A multicenter retrospective study

Lateral flow immunoassay (LFA) detection of cryptococcal capsular polysaccharide antigen (CrAg) is reported to be the most rapid and convenient laboratory method for diagnosing cryptococcosis. Its clinical diagnostic use, however, is not well studied. We retrospectively analyzed the data from 97 patients with suspected pulmonary cryptococcosis (PC) at 2 tertiary care centers. CrAg in both serum and lung aspirate specimens were examined by LFA. We divided the patients who were diagnosed with PC into group I, patients positive for CrAg in both the serum and lung aspirate, and group II, patients positive for CrAg in the lung aspirate but not in the serum. We analyzed the differences in imaging distribution, morphological characteristics, and concomitant signs between the 2 groups. Of all 97 patients, 47 were diagnosed with PC. Lung aspirates were positive for CrAg in 46/47 patients with PC (sensitivity 97.9%, specificity 100%, positive predictive value = 100%, negative predictive value = 98%). There were no false positive results in the noncryptococcosis patients, revealing a diagnostic accuracy of 99%. Serum CrAg tests were positive in 36/47 patients with PC (sensitivity 76.6%, specificity 100%, accuracy 88.7%, positive predictive value = 100%, negative predictive value = 82%). Chest imaging data showed a statistically significant greater number of single lesions in group II than in group I (P < .05). More lesions accompanied by halo signs were showed in group I (P < .01), whereas more accompanied by pleural stretch signs were found in group II (P < .01). The LFA-positive rate of CrAg in lung aspirate samples was higher than that of the serum samples, especially in patients with single pulmonary lesion or in those accompanied by pleural stretch. The direct measurement of CrAg in lung aspirate is a rapid, useful alternative diagnostic method for PC confirmation.

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.

Performance of the Colloidal Gold Immunochromatography of Cryptococcal Antigen on Bronchoalveolar Lavage Fluid for the Diagnosis of Pulmonary Cryptococcosis

Objective

This study aimed to investigate the efficacy of the colloidal gold immunochromatography method in the detection of Cryptococcus antigen in bronchoalveolar lavage fluid (BALF) for pulmonary cryptococcosis (PC) diagnosis.

Methods

A total of 111 patients with clinically suspected PC who were finally diagnosed with nonhuman immunodeficiency virus infection and hospitalized in the Ningbo First Hospital from March 2017 to December 2021 were retrospectively analyzed. All the confirmed cases were divided into two groups as follows: the PC group (33 cases) and the non-PC group (78 cases). All the patients were subjected to serum and BALF cryptococcal capsular polysaccharide antigen-lateral flow immunochromatographic assay (CrAg-LFA) and etiological culturing.

Results

In the PC group, serum CrAg-LFA was positive for 24 and negative for 9 cases, serum Cryptococcus culture was positive for 1 and negative for 32 cases, BALF CrAg-LFA was positive for 31 and negative for 2 cases, and BALF Cryptococcus culture was positive for 9 and negative for 24 cases. In the non-PC group, serum CrAg-LFA was positive for 1 and negative for 77 cases, serum culture was negative in all the cases, and both BALF CrAg-LFA and culture were negative in all the cases. The sensitivity, specificity, and accuracy of BALF CrAg-LFA for PC diagnosis were 93.9%, 100%, and 98.2%, respectively, whereas those of BALF culture were 27.3%, 100%, and 78.4%, respectively. The sensitivity and accuracy of BALF CrAg-LFA were higher than that of serum CrAg-LFA and BALF etiological culture with statistically significant differences (p < 0.05).

Conclusion

The diagnostic value of BALF CrAg-LFA for PC is superior to that of serum CrAg-LFA and BALF etiological culture.

Clinical characteristics and image features of pulmonary cryptococcosis: a retrospective analysis of 50 cases in a Chinese hospital

Objective

To investigate the clinical manifestations and imaging characteristics of pulmonary cryptococcosis, and discuss its guidance in diagnosing.

Methods

The clinical data of patients diagnosed with cryptococcosis in our hospital from January 2014 to May 2020 were collected and retrospectively analyzed. Patients were divided into the immunocompromised group and the immunocompetent group. The symptomatic features, laboratory examination, imaging manifestations, and curative effect were analyzed.

Results

The most common symptoms of patients were cough and sputum production, followed by fever. The immunocompetent group has a significantly higher accident rate of cough and fever than the immunocompromised group, while the immunocompromised group has a significantly higher accident rate of headache and dizziness (P < 0.05). The positive rate of serum cryptococcal capsular antigen (CrAg) test of the two groups were 83.33% and 86.96%, respectively. While the positive rate of CrAg test in cerebrospinal fluid of the immunocompromised group was significantly higher than that of the immunocompetent group (P < 0.05). The lesions of pulmonary cryptococcosis were predominantly present in the lower part of the lung periphery and significantly distributed in the right lung (P < 0.05). The most common imaging finding of pulmonary cryptococcosis was halo sign (64.58%), followed by multiple nodules, and trachea sign was significantly more common in the immunocompetent group.

Conclusions

Cryptococcosis has an insidious onset, which can infect healthy people as well. Conducting a CrAg test is good for screening and diagnosing cryptococcosis. We should be alert for the high risk of cryptococcal meningoencephalitis in patients with compromised immune function.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01930-2.

Pulmonary cryptococcosis misdiagnosed as lung cancer in a man with normal immune function: A case report

Pulmonary cryptococcosis is an opportunistic infection of cryptococcus both in immunocompetent and immunocompromised patients, who suffered from HIV infection, organ transplantation, diabetes mellitus, corticosteroid or immunosuppressive therapy, and malignancy. Pulmonary cryptococcosis is the commonest location of non-central nervous system cryptococcosis and usually presents with nonspecific symptoms. It often shows shadows on the lung, which makes it difficult to distinguish it from lung cancer. Here we report a case of a 52-year-old man with pulmonary cryptococcosis, who was misdiagnosed as lung cancer. Clinicians need to consider the possibility of pulmonary cryptococcosis and the importance of lung biopsy when treating a patient with a normal immune function that has isolated pulmonary nodules. This case also indirectly illustrates the importance of percutaneous lung biopsy in patients with isolated pulmonary nodules.

Evaluation of IFN-γ secretion after stimulation with C. neoformans and C. gattii antigens in individuals with frequent exposure to the fungus

In this study we produced antigenic extracts from prototypical strains of C. neoformans (VNI-VNIV) and C. gattii (VGI-VGIV) and tested IFN-γ secretion by Elispot. Antigens from the eight Cryptococcus molecular types (VNI -VNIV and VGI - VGIV) were obtained after capsule reduction. IFN-γ secretion by Elispot method were stimulated with C. neoformans and C. gattii antigens. Peripheral blood mononuclear cells of fourteen healthy control subjects, being: five ecotourists, two mycologists, three poultry keepers, and four individuals without reports of exposure to the fungus. We observed a significant increase in IFN-γ secretion in the group of ecotourists, mycologists and bird keepers in relation to the group of individuals without reports of occupational exposures to these agents. Our results suggest the significant increase in IFN-γ secretion may be related to the continuous exposure of these groups of individuals to the fungus, as well as to the specific antigen memory immune response developed during exposure to Cryptococcus.

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.

Cryptococcosis by Cryptococcus neoformans/Cryptococcus gattii Species Complexes in non-HIV-Infected Patients in Southeastern Brazil

INTRODUCTION:

The clinical manifestations of cryptococcosis are usually associated with the infecting agents Cryptococcus neoformans (CN) and C. gattii (CG) species complexes and the host. In this study, non-HIV-infected patients, at a university hospital in southeastern Brazil, had epidemiological and clinical data associated with cryptococcal disease and isolated Cryptococcus species: CN - 24 patients and CG - 12 patients.

METHODS:

The comparison was comprised of demographic data, predisposing factors, clinical and laboratory manifestations, and outcomes of cryptococcosis patients treated between 2000 and 2016. Immunocompetent and immunosuppressed patients were also compared, irrespective of the infecting species. Cryptococcus spp. were genotyped by PCR-RFLP analysis of the URA5 gene.

RESULTS:

Infections by the CN species complex (100% VNI genotype) were associated with drug immunosuppression and fungemia, and patients infected with the CG species complex (83% VG II and 17% VGI genotypes) had more evident environmental exposure and higher humoral response. CN and CG affected patients with or without comorbidities.

CONCLUSIONS:

Diabetes mellitus, other chronic non-infectious diseases, and alcoholism were likely predisposing factors for infection by both CN and CG species. Immunocompetent patients, independent of the infecting Cryptococcus species complexes, showed a higher occurrence of meningitis and a trend toward less fungal dissemination and longer survival than immunosuppressed hosts.

Disseminated Cryptococcosis in an Immunocompetent Child

Disseminated cryptococcosis in children is a classic affliction associated with human immunodeficiency virus (HIV) infection or primary inherited immunodeficiency disorders (PID) with central nervous system being the most common site of dissemination. We report a rare case of disseminated cryptococcosis in an 11-year-old girl who presented with pulmonary involvement, hepatosplenomegaly, and generalized lymphadenopathy. No known inherited or acquired immune deficiencies were identified after a comprehensive laboratory work-up including genetic sequencing. She responded well to anti-fungal therapy (flucytosine and amphotericin followed by fluconazole) and is on regular follow-up. 

Update on Pulmonary Cryptococcosis

Pulmonary cryptococcosis is a common but underdiagnosed opportunistic fungal infection in both immunocompromised and immunocompetent patients. The causal agents include at least eight evolutionary distinct haploid lineages as well as their hybrids of the human pathogenic Cryptococcus complex. In this update, we review recent advances in epidemiology, mode of transmission, risk factors, diagnostic methods, and therapy of pulmonary cryptococcosis. Our review suggests significant challenges and opportunities for research, from bedside to benchside and back to bedside.

Comparison of clinical features of pulmonary cryptococcosis with and without central nervous system involvement in China

Objective

This study aimed to compare the clinical features of pulmonary cryptococcosis (PC) in patients with and without central nervous system (CNS) involvement.

Methods

We retrospectively reviewed demographics, presenting symptoms, radiographic features, and laboratory findings of patients diagnosed with PC in 28 hospitals from 2010 to 2019. Risk factors for CNS involvement were analyzed using logistic regression models.

Result

A total of 440 patients were included, and 36 (8.2%) had CNS involvement. Significant differences in fever, headache, and chills occurred between the two groups (overall and with/without CNS involvement) for fever (17.8% [78/440]; 52.8% vs. 14.6% of patients, respectively), headache (4.5% [20/440]; 55.6% vs. 0% of patients, respectively), and chills (4.3% [19/440]; 13.9% vs. 3.5% of patients, respectively). The common imaging manifestation was nodules (66.4%). Multivariate analysis showed that cavitation (adjusted odds ratio [AOR] = 3.552), fever (AOR = 4.182), and headache were risk factors for CNS involvement. Routine blood tests showed no differences between the groups, whereas in cerebrospinal fluid the white blood cell count increased significantly and glucose decreased significantly.

Conclusion

In patients with PC, the risk of CNS involvement increases in patients with headache, fever, and cavitation; these unique clinical features may be helpful in the diagnosis.

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.

Clinical analysis in immunocompetent and immunocompromised patients with pulmonary cryptococcosis in western China

Cryptococcosis is a systemic infection and it may occur in immunocompromised and immunocompetent hosts. In order to better understand the clinical characteristics of patients with PC in different immune status, we retrospectively investigated the clinical, radiological, and treatment profiles of immunocompetent and immunocompromised patients with PC during a 10-year period (2008–2017). As a result, out of 136 patients, 94 (69.1%) were immunocompromised hosts. For the PC patients without CNS involvement, higher percentage of immunocompetent patients (39.5%, 15/38) had asymptomatic presentation than immunocompromised patients (6.3%, 3/48) (P < 0.05). Multiple pulmonary nodules (72.7%, 56/77), ground-glass attenuation/interstitial changes (94.4%, 17/18) and cavitation (88.6%, 31/35) were significantly frequent in immunocompromised patients (P < 0.05). A total of 47 patients were misdiagnosed as tuberculosis or tumors based on CT signs. PC was likely to be misdiagnosed as tuberculosis in immunocompromised patients (88.2%, 15/17), and tumor was more likely to be considered in immunocompetent patients (43.3%, 13/30). Immunocompetent patients accounted for 80% (24/30) of patients with definite diagnosis on surgical lung biopsy. Fluconazole monotherapy can achieve good clinical outcome in most PC patients without central nervous system (CNS) involvement (91.5%, 54/59). After 3 months of treatment, 92.7% (38/41) patients have improved imaging findings. In conclusion, PC has diverse imaging manifestations and it is easily misdiagnosed. Lobectomy should be carefully selected in immunocompetent patients with a single lung lesion. Fluconazole monotherapy is preferred for PC patients without CNS involvement.

Pulmonary cryptococcosis characteristics in immunocompetent patients-A 20-year clinical retrospective analysis in China

Background

Pulmonary cryptococcosis (PC) is not considered an rare, opportunistic infection anymore. The immunocompetent population accounts for an increasing proportion of the morbidity.

Objective

This study investigated the clinical characteristics of PC patients spanning 20 years, in a referral centre of China.

Patients/Methods

We retrospectively investigated the clinical data of 99 patients with PC who were diagnosed at Peking Union Medical College Hospital (PUMCH) from January 1998 to December 2017.

Results

Pulmonary cryptococcosis incidence in PUMCH has seen sharp increase in two decades. There were 40.4% (40/99), 17.2% (17/99) and 42.4% (42/99) immunocompetent, mildly immunocompromised and severe immunocompromised patients, respectively. Significantly higher (P = .035) male predominance in immunocompetent and mildly immunocompromised groups (68.4%, 39/57) compared with severe immunocompromised group (45.2%, 19/42) was found. Overall, 27.5% (11/40) immunocompetent patients reported a significant difference (P = .02) in history of more than weekly drinking, higher than mildly or severe immunocompromised. No significant difference occurred in symptoms and radiographic characteristics among the groups. In pulmonary computerised tomography findings, the non‐air pathway feature was the dominant distribution characteristics in all patients with PC (P = .002). The gap in body dissemination frequency between immunocompetent combined with mildly immunocompromised (5.26%, 3/57) and severe immunocompromised (19.0%, 8/42) was marginally significant (P = .05).

Conclusions

Gender and alcohol drinking could be PC risk factors of concern in patients without severe immunodeficiency. No significant difference occurred in symptoms or radiographic characteristics between patients with different levels of immune status. The unique radiographic non‐air pathway distribution in the lung may be the feature of Cryptococcus invasion that may enhance accurate diagnosis.