Clinical and radiographic presentations of pulmonary cryptococcosis in immunocompetent patients

Abstract

Pulmonary cryptococcosis is often noted in immunocompromized patients, especially in HIV-seropositive patients and post-transplant patients. Only a few case reports and small-scale studies on pulmonary cryptococcosis in immunocompetent patients have been published in the English literature. However, there are several areas of uncertainty in this group of patients including image presentations and management strategy. This retrospective study including 17 patients is designed to share our 7 y of experience in clarifying the characteristics of pulmonary cryptococcosis in immunocompetent patients, including initial symptoms, diagnostic criteria, pulmonary imaging, treatment and outcome in a tertiary teaching hospital in Taiwan.

Clinical and radiologic manifestations of pulmonary cryptococcosis in immunocompetent patients and their outcomes after treatment

“…Although most of our patients also had unilobar pulmonary involvement, a finding that was different from previous studies showing multiple lesions, multilobar, or bilateral pulmonary involvement (5-10), and the sizes of the pulmonary nodules, masses and/or consolidations in our patients were more variable, ranging from <1 cm up to 15 cm in greatest diameter. The distinct peripheral, subpleural, and lower lung predominance in the present study was similar only to the findings reported by Fox and Müller (6) and Yang et al (8) but was in contrast to other previous studies showing upper or middle lung predominance mimicking tuberculosis (5,10) or no lobar predilection (4, 9). CT, computed tomography; CXR, chest radiograph; F, female; M, male; NA, not available.…”

“…Calcification within the pulmonary lesion, as shown in one of our cases, is also rare (14,15,17,18). Surrounding groundglass opacity or the CT halo sign, as found in our study, and isolated groundglass opacity (6,(8)(9)(10)(11)17) can be observed. Although centrilobular or satellite nodules have been described (6,8), tree-inbud appearance was observed neither in the present nor in previous studies (6)(7)(8)(9).…”

“…Surrounding groundglass opacity or the CT halo sign, as found in our study, and isolated groundglass opacity (6,(8)(9)(10)(11)17) can be observed. Although centrilobular or satellite nodules have been described (6,8), tree-inbud appearance was observed neither in the present nor in previous studies (6)(7)(8)(9). Therefore, we suggest that the presence of nonenhanced low-attenuation areas within the areas of consolidation or mass having peripheral, subpleural and lower lung predominance, as shown in the present study, should raise the concern for pulmonary cryptococcosis, particularly in a patient presenting with meningitis.…”

“…Cavitation and air-filled bronchograms within nodules or consolidation, observed in 58.3% of our cases, have been variably demonstrated in previous studies, ranging from 0% to 42% of cases (4)(5)(6)(7)(8)(9)(10)(11)15). Nonenhanced, low-attenuation areas within the areas of consolidation or masses, previously shown to represent gelatinous collections of large numbers of fungal organisms or rarely ischemic necrosis (12,15,16) were also frequently demonstrated on CT images in our study but have rarely been described (17).…”

“…In rare circumstances, the infection occurs in otherwise healthy individuals. According to previous studies from many countries in North America, Europe, and the East (3)(4)(5)(6)(7)(8)(9)(10)(11), most immunocompetent individuals have mild or no clinical symptoms with isolated pulmonary involvement through single or multiple small pulmonary nodules. These findings are somewhat different from the more aggressive clinical and radiographic findings described in isolated case reports among Thai immunocompetent patients (6,(12)(13)(14) and in a study from South America (3).…”