An Atypical Cause of Hemoptysis

Abstract

SESSION TITLE: Fungal Infections 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Cryptococcus presenting as an endobronchial mass lesion is rare. We present an unusual case of pulmonary cryptococcosis in an immunocompetent patient encountered in clinical practice. CASE PRESENTATION: Patient is a 48y/o AAF with a past medical history notable for cough variant asthma, and hypertension. She had a persistent cough for many years. Initial imaging performed for work-up of her chronic cough was unremarkable. Full pulmonary function test were normal. Ig E levels were elevated at 255 kU/L with immunocap testing revealing high levels of reactivity to dust mites, animal dander and grasses. The patient was managed with formoterol/ mometasone and an albuterol rescue inhaler as needed with variable compliance. She presented for re-evaluation after she noted a change in her cough for several months. Her cough had initially been dry but had become productive a small amount of blood tinged sputum. She was seen in the emergency department shortly after the onset of hemoptysis and was told that she had pneumonia. She was discharged on a 7 day course of levofloxacin without a significant improvement in her symptoms. CT scan of the chest performed 3 months after the onset of symptoms showed a right lower lobe mass like consolidation (Figure 1). The patient continued to experience a chronic cough with intermittent hemoptysis, describing it as “puddles of blood in my phlegm” more frequently in the morning. At that time, she also complained of worsening dyspnea with exertion, polyarthralgias and fatigue. Antinuclear antibody, antineutrophil cytoplasmic autoantibodies and rheumatoid factor were negative. Fiberoptic bronchoscopy revealed an endobronchial mass obstructing the one of the right lower lobe medial basilar subsegments. Bronchoalveolar lavage demonstrated budding yeasts, positive fungal stains and endobronchial biopsy of the mass had innumerable intracellular yeast forms with a clear capsule suggestive of Cryptococcus (figure 2). Patient was started on itraconazole. DISCUSSION: The clinical presentation of Cryptococcus is highly variable and often related to the burden of exposure, virulence factor or quality of immune response[1]. In the immunocompetent host primary infection is usually asymptomatic. These patients are usually identified incidentally by abnormal chest imaging or on biopsy of a lung mass or on cultures of lung specimens obtained for other reasons[2,3]. Cough is the most common pulmonary symptom if the patient is symptomatic. CONCLUSIONS: Pulmonary cryptococcosis has a wide range of presentations and should be considered as a cause of chronic cough even in immunocompetent patients. Reference #1: Jarvis JN1, Harrison TS. Pulmonary cryptococcosis. Semin Respir Crit Care Med. 2008 Apr;29(2):141-50. doi: 10.1055/s-2008-1063853. Reference #2: Lindell RM1, Hartman TE, Nadrous HF, Ryu JH. Pulmonary cryptococcosis: CT findings in immunocompetent patients. Radiology. 2005 Jul;236(1):326-31. DISCLOSURE: The following authors have nothing to disclose: Valentina Amaral, Kala Davis-McDonald No Product/Research Disclosure Information