Atypical Radiographic Presentation of Cryptococcus Pneumonia in a Newly Diagnosed HIV Patient

Abstract

Background. Cryptococcus infection is an opportunistic infection that occurs primarily among immunocompromised patients, and the morbidity and mortality of this infection is high if left unrecognized and untreated. There are no clinical or radiographic characteristics typical of cryptococcal pneumonia, and its clinical and radiological presentations often overlap with other diagnoses. Case Presentation. We present a case of a 25-year-old man from Ghana admitted for an altered mental state, weight loss, neck pain, fever, and photophobia. He was diagnosed with Cryptococcus neoformans meningitis by cerebrospinal fluid culture and with disseminated cryptococcal infection by a positive Cryptococcus blood test. Diffuse micronodular opacities were found in a miliary pattern in the upper portions of both lungs upon imaging, which suggested miliary tuberculosis; thus, the patient was started on antituberculosis therapy. The patient underwent flexible fiber optic bronchoscopy, and transbronchial biopsy of the right lung showed bronchopneumonia with fungal spores consistent with filamentous Cryptococcus neoformans, which grew in tissue culture of the right lung. Interferon-gamma release assay, Mycobacterium tuberculosis PCR, and acid-fast bacilli staining of the bronchoalveolar lavage were negative for the M. tuberculosis complex. Conclusion. The similarities in clinical and imaging findings among patients with acute immunodeficiency syndrome with coinfections make diagnoses difficult; thus image-guided biopsies are essential to confirm diagnoses.

Epidemiology of Cryptococcus and cryptococcosis in Western Africa

“…This was the first reported case of an HIV patient diagnosed with cryptococcal pneumonia using flexible fiberoptic bronchoscopy (FFB) with transbronchial biopsy (TBBx). Image‐guided biopsies are necessary to obtain confirmatory results in patients co‐infected with HIV because there may be an overlap in clinical presentations as observed in this case 56 …”

“…The authors concluded that IRIS may not only occur as a paradoxical reaction with increase in symptoms associated with tuberculosis, but may as well reveal unknown infections like cryptococcosis. 50 Cacacho et al 56 CSF and blood analysis showed that the patient was infected with…”

“…Image-guided biopsies are necessary to obtain confirmatory results in patients coinfected with HIV because there may be an overlap in clinical presentations as observed in this case. 56…”

“…The authors concluded that IRIS may not only occur as a paradoxical reaction with increase in symptoms associated with tuberculosis, but may as well reveal unknown infections like cryptococcosis 50 . Cacacho et al 56 recently reported the unusual radiographic presentation of Cryptococcus pneumonia in a 25‐year‐old man who was newly diagnosed with HIV infection. The patient tested negative for Mycobacterium tuberculosis complex.…”

A Case of Miliary Pulmonary Cryptococcosis Showing Different Changes in Computed Tomography Images of the Left and Right Lungs

“…The most typical findings of the disease on computed tomography (CT) are single or multiple nodules, whereas nonspecific findings, such as ground-glass opacity (GGO), infiltration shadows, and pleural effusions, are particularly observed in immunocompromised patients 3) . Although rare, miliary nodules suggestive of miliary tuberculosis have also been reported in immunocompromised patients with cryptococcosis [4][5][6] . In addition, serial CT changes of pulmonary cryptococcosis, particularly miliary cryptococcosis, are not well understood.…”