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Yamamoto R, Tobino K, Sogabe S, Saitou Y, Obata Y. Cryptococcal Pleuritis in an Immunocompetent Patient: A Case Report and Literature Review. Cureus 2024; 16:e60260. [PMID: 38872700 PMCID: PMC11170230 DOI: 10.7759/cureus.60260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2024] [Indexed: 06/15/2024] Open
Abstract
Cryptococcosis, primarily an opportunistic infection, often occurs in immunocompromised patients but can also affect immunocompetent individuals. Cryptococcosis typically manifests in the lungs, but pleurisy is rare, particularly in immunocompetent patients. This report details a case of cryptococcal pleuritis in a 74-year-old immunocompetent male with a history of heart failure, presenting initially with pleural effusion. Diagnostic challenges arose due to the initial absence of intrapulmonary lesions. The diagnosis was eventually established through a surgical biopsy and tissue culture, revealing Cryptococcus neoformans. This case underscores the complexity of diagnosing cryptococcal infections, particularly in immunocompetent patients, and highlights the need for considering cryptococcosis in differential diagnoses of lymphocyte-predominant exudative pleural effusions.
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Affiliation(s)
| | | | | | | | - Yumi Obata
- Respiratory Medicine, Iizuka Hospital, Fukuoka, JPN
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Lee J, Park BE, Jang SY, Kim CH. Isolated cryptococcal pleural effusion in a heart transplant recipient: A case report and literature review of pleural fluid adenosine deaminase levels. Respirol Case Rep 2024; 12:e01297. [PMID: 38371460 PMCID: PMC10872933 DOI: 10.1002/rcr2.1297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 02/06/2024] [Indexed: 02/20/2024] Open
Abstract
Isolated cryptococcal pleural effusion is rare as the initial clinical presentation in opportunistic cryptococcal infection. We describe a 59-year-old male heart transplantation recipient who presented with a mononuclear-leukocyte-predominant exudative pleural effusion, with adenosine deaminase levels (ADA) of 37 IU/L and focal pleural nodularity on computed tomography. A thorough evaluation, including pleural fluid culture, cryptococcal antigen, and histological examination, led to the diagnosis of cryptococcal pleural effusion. Antifungal therapy with fluconazole of 400 mg/day showed clinical and radiological improvement. A literature review identified six cases of cryptococcal pleural effusion that reported pleural fluid ADA levels. All cases, including the present one, involved immunocompromised hosts and exhibited a mononuclear-leukocyte-predominant exudate. High pleural fluid ADA levels were observed in approximately half of these cases. The pleural fluid cryptococcal antigen test was an important diagnostic tool for early diagnosis. In an era where immunocompromised hosts are increasing, cryptococcal infection should be considered as a potential aetiology in immunosuppressed patients with an exudative pleural effusion of unknown cause, even if ADA levels are elevated.
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Affiliation(s)
- Jaehee Lee
- Department of Internal MedicineKyungpook National University, School of MedicineDaeguRepublic of Korea
| | - Bo Eun Park
- Department of Internal MedicineKyungpook National University, School of MedicineDaeguRepublic of Korea
| | - Se Yong Jang
- Department of Internal MedicineKyungpook National University, School of MedicineDaeguRepublic of Korea
| | - Chang Ho Kim
- Department of Internal MedicineKyungpook National University, School of MedicineDaeguRepublic of Korea
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Howard-Jones AR, Sparks R, Pham D, Halliday C, Beardsley J, Chen SCA. Pulmonary Cryptococcosis. J Fungi (Basel) 2022; 8:1156. [PMID: 36354923 PMCID: PMC9696922 DOI: 10.3390/jof8111156] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/26/2022] [Accepted: 10/29/2022] [Indexed: 07/25/2023] Open
Abstract
Pulmonary cryptococcosis describes an invasive lung mycosis caused by Cryptococcus neoformans or Cryptococcus gattii complex. It is often a high-consequence disease in both immunocompromised and immunocompetent populations, and may be misdiagnosed as pulmonary malignancy, leading to a delay in therapy. Epidemiology follows that of cryptococcal meningoencephalitis, with C. gattii infection more common in certain geographic regions. Diagnostic tools include histopathology, microscopy and culture, and the detection of cryptococcal polysaccharide antigen or Cryptococcus-derived nucleic acids. All patients with lung cryptococcosis should have a lumbar puncture and cerebral imaging to exclude central nervous system disease. Radiology is key, both as an adjunct to laboratory testing and as the initial means of detection in asymptomatic patients or those with non-specific symptoms. Pulmonary cryptococcomas (single or multiple) may also be associated with disseminated disease and/or cryptococcal meningitis, requiring prolonged treatment regimens. Optimal management for severe disease requires extended induction (amphotericin B and flucytosine) and consolidation therapy (fluconazole) with close clinical monitoring. Susceptibility testing is of value for epidemiology and in regions where relatively high minimum inhibitory concentrations to azoles (particularly fluconazole) have been noted. Novel diagnostic tools and therapeutic agents promise to improve the detection and treatment of cryptococcosis, particularly in low-income settings where the disease burden is high.
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Affiliation(s)
- Annaleise R. Howard-Jones
- Centre for Infectious Diseases & Microbiology Laboratory Services, New South Wales Health Pathology—Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2145, Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2145, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW 2006, Australia
| | - Rebecca Sparks
- Centre for Infectious Diseases & Microbiology Laboratory Services, New South Wales Health Pathology—Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2145, Australia
| | - David Pham
- Centre for Infectious Diseases & Microbiology Laboratory Services, New South Wales Health Pathology—Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Catriona Halliday
- Centre for Infectious Diseases & Microbiology Laboratory Services, New South Wales Health Pathology—Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Justin Beardsley
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2145, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW 2006, Australia
- Westmead Institute for Medical Research, Westmead, NSW 2145, Australia
| | - Sharon C.-A. Chen
- Centre for Infectious Diseases & Microbiology Laboratory Services, New South Wales Health Pathology—Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2145, Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2145, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW 2006, Australia
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Haider MS, Master M, Mahtani A, Guzzo E, Khalil A. Cryptococcal Pneumonia in an Immunocompetent Patient: A Rare Occurrence. Cureus 2022; 14:e29841. [PMID: 36348868 PMCID: PMC9632677 DOI: 10.7759/cureus.29841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2022] [Indexed: 11/05/2022] Open
Abstract
Cryptococcosis is an invasive yeast infection commonly found among immunosuppressed patients. Pulmonary cryptococcal infection can have variable presentations ranging from pulmonary nodules and masses to consolidation. A patient can present with shortness of breath, cough, sputum production, chest pain, fatigue, and weight loss. Diagnosis can be made using fungal culture, histology, radiographic findings, and cryptococcal antigen in serum as well as in the cerebrospinal fluid. Treatment is usually with a combination or a single antifungal agent. Few cases have been reported in immunocompetent individuals. Here we present a case of 69-year-old immunocompetent individual, who was initially seen in the outpatient clinic for dyspnea, cough, and fatigue and was treated for pneumonia. The patient remained symptomatic despite multiple courses of oral antibiotics. He was then sent for inpatient admission. CT scan was obtained that showed patchy infiltrates and consolidations, followed by bronchoscopy. The cytology confirmed adenocarcinoma. The fungal smear and culture grew Cryptococcus neoformans. The patient was treated with fluconazole with improvement of his symptoms before starting chemotherapy. We are reporting this case as clinicians usually focus on bacterial etiologies in outpatient setting. Our patient, who was immunocompetent, had a new diagnosis of cryptococcal pneumonia and was also found to have lung adenocarcinoma. This case highlights the rare occurrence of this type of pneumonia in immunocompetent patients and the importance of considering fungal causes of pneumonia in patients.
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Georgakopoulou VE, Damaskos C, Sklapani P, Trakas N, Gkoufa A. Pleural involvement in cryptococcal infection. World J Clin Cases 2022; 10:5510-5514. [PMID: 35812673 PMCID: PMC9210898 DOI: 10.12998/wjcc.v10.i16.5510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/30/2022] [Accepted: 04/30/2022] [Indexed: 02/06/2023] Open
Abstract
Pleural involvement of cryptococcal infection is uncommon and is more commonly observed in immunocompromised hosts than in immunocompetent ones. Pleural involvement in cryptococcal infections can manifest with or without pleural effusion. The presence of Cryptococcus spp. in the effusion or pleura is required for the diagnosis of cryptococcal pleural infection, which is commonly determined by pleural biopsy, fluid culture, and/or detection of cryptococcal antigen in the pleura or pleural fluid.
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Affiliation(s)
| | - Christos Damaskos
- Department of Infectious Diseases, Laiko General Hospital, Athens 11527, Greece
| | - Pagona Sklapani
- Department of Infectious Diseases, Laiko General Hospital, Athens 11527, Greece
| | - Nikolaos Trakas
- Department of Infectious Diseases, Laiko General Hospital, Athens 11527, Greece
| | - Aikaterini Gkoufa
- Department of Infectious Diseases, Laiko General Hospital, Athens 11527, Greece
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Maiese A, La Russa R, Arcangeli M, Volonnino G, De Matteis A, Frati P, Fineschi V. Multidisciplinary approach to suspected sudden unexpected infant death caused by milk-aspiration: A case report. World J Clin Cases 2020; 8:4128-4134. [PMID: 33024771 PMCID: PMC7520785 DOI: 10.12998/wjcc.v8.i18.4128] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/02/2020] [Accepted: 08/26/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The term sudden unexpected infant death (SUID) is not always properly invoked. It refers to a broad range of conditions that sometimes defy classification. There is not only a strong emotional impact on the family, but such cases are also quite complex. Underlying causes may be multiple, not always readily apparent, and have potential repercussions, especially in terms of forensics.
CASE SUMMARY A 5-month-old male baby was pronounced dead following acute lung failure and cardiopulmonary arrest. The parents had immediately rushed their child to the hospital, stating the baby was found prone and not breathing. Total-body postmortem computed tomography (PMCT) was performed, revealing a hypodense material of indeterminate nature within the main airways and areas of ground-glass parenchymal change. At autopsy, the respiratory tract mucosa appeared edematous and was coated with a whitish stringy material. There was widespread airspace reduction due to parenchymal collapse. Alveolar sacs and bronchial openings contained abundant amorphous material admixed with white blood cells. Immunohistochemical studies were performed, targeting CD15, CD68, and alpha-lactalbumin. Ultimately, the focus was on alpha-lactalbumin (milk protein), which showed marked immunopositivity within alveolar spaces. Cytoplasmic staining of macrophages was also particularly prominent.
CONCLUSION Postmortem investigations are thus essential to identify causes of death and surrounding circumstances. PMCT is a useful tool in this setting, given the frequent dearth of autopsy findings and ambiguity as to cause of death in SUID cases. These findings, later confirmed by immunohistochemical investigations, were indicative of active pneumonia due to aspirated milk. The present account illustrates the importance a broad diagnostic approach to SUID in cases of forensic concern. PMCT is a very valuable aid in cases of forensic interest, as it can provide useful information in all those situations in which the cause of death is uncertain or there are no suggestive dynamics or lesions.
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Affiliation(s)
- Aniello Maiese
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, Pisa 56126, Italy
| | - Raffaele La Russa
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza University of Roma, Roma 00185, Italy
| | - Mauro Arcangeli
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila 67100, Italy
| | - Gianpietro Volonnino
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza University of Roma, Roma 00185, Italy
| | - Alessandra De Matteis
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza University of Roma, Roma 00185, Italy
| | - Paola Frati
- Department SAIMLAL, Sapienza University of Roma, Roma 00185, Italy
| | - Vittorio Fineschi
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza University of Roma, Roma 00185, Italy
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