Massive mediastinal cryptococcosis in a young immunocompetent patient Shotaro Okachi1, Keiko Wakahara1, Daizo Kato2, Takashi Umeyama3, Tetsuya Yagi2 & Yoshinori Hasegawa1 1
Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan. Department of Infectious Diseases, Nagoya University Hospital, Nagoya, Japan. 3 Department of Chemotherapy and Mycoses, National Institute of Infectious Diseases, Tokyo, Japan. 2
Keywords Cryptococcosis, EBUS-TBNA, lymphadenopathy, mediastinum, pulmonary. Correspondence Shotaro Okachi, Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan. E-mail: [email protected]
Received: 25 February 2015; Revised: 16 April 2015; Accepted: 01 May 2015.
Abstract Pulmonary cryptococcosis with lymph node involvement is relatively rare in immunocompetent patients. We report a case of pulmonary cryptococcosis with massive mediastinal lymphadenopathy in an immunocompetent young patient. In this report, a 17-year-old boy presented with high-grade fever and persistent cough. Chest X-ray and computed tomography showed massive mediastinal lymphadenopathy. Endobronchial ultrasound-guided transbronchial needle aspiration revealed histological evidence of cryptococcal lymphadenitis. He was treated with liposomal amphotericin B plus flucytosine followed by fluconazole and recovered.
Respirology Case Reports 2015; 3(3): 95–98 doi: 10.1002/rcr2.111
Introduction Pulmonary cryptococcosis is generally more severe in those who are immunocompromised and is often accompanied by disseminated infection, including central nervous system (CNS) disease . Although the disease occurs in both immunocompetent and immunocompromised hosts, the occurrence of massive cryptococcal lymphadenopathy is rare . We report a case of massive cryptococcal lymphadenopathy in a young immunocompetent patient.
Case Report A 17-year-old otherwise healthy boy was admitted to a local hospital with cough for 1 month and high-grade fever for 1 week. He was subsequently referred to our institution on the suspicion of mediastinal tumor.
The patient had not been exposed to pigeons. He had no habit of smoking or consuming alcohol. His body temperature was 39.4°C. He looked ill and his right supraclavicular lymph node was slightly palpable. Blood examination findings revealed a white blood cell count of 12,900 cells/mm3 and a C-reactive protein level of 20.32 mg/dL (Table 1). Blood culture showed no organism growth. Chest X-ray and computed tomography (CT) (Fig. 1A–C) showed swollen mediastinal lymph nodes compressing the trachea and an area of consolidation with cavitation in the right upper lobe. Differential diagnosis included mediastinal tumor (e.g. lymphoma), tuberculosis, and fungal infection at that point. Conventional bronchoscopy and endobronchial ultrasoundguided transbronchial needle aspiration (EBUS-TBNA) were performed for diagnosis. Paratracheal and subcarinal lymph nodes were punctured and bronchoscopic findings revealed
© 2015 The Authors. Respirology Case Reports published by John Wiley & Sons Ltd on behalf of The Asian Pacific Society of Respirology. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.
Massive mediastinal cryptococcosis
S. Okachi et al.
Table 1. Results of blood tests Complete blood count WBC Seg. Eos. Mono. Lym. CD4 RBC Hb Plt Blood chemistry TP Alb GOT GPT LDH ALP T.bil Na K Cl Ca BUN Cre ACE Glu
Immunological and serological test 12,900/mm3 78% 4% 7% 7% 31% 433 × 104/mm3 12.9 g/dL 52 × 104/mm3 6.8 g/dL 2.4 g/dL 41 IU/ 77 IU/L 253 IU/L 590 IU/L 0.4 mg/dL 139 mEq/L 4.8 mEq/L 102 mEq/L 9 mg/dL 5 mg/dL 0.59 mg/dL 8.8 IU/L 97 mg/dL
CRP IgG IgA IgM sIL-2R HIV antibody HTLV-1 antibody Cryptococcal antigen Anti-IFN γ antibodies Anti-GM-CSF autoantibodies Endocrinological test βHCG Tumor marker CEA SCC ProGRP AFP
20.32 mg/dL 1651 mg/dL 476 mg/dL 107 mg/dL 1410 U/mL Negative Negative Negative Negative Negative