INCIDENTAL LUNG MASS PRESENTING AS CRYPTOCOCCOMA

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Cryptococcus neoformans is one of the most common invasive fungal organisms worldwide and is associated with significant morbidity and mortality. Here, we present a case of a patient with a lung mass suspicious for malignancy but confirmed to be cryptococcoma. CASE PRESENTATION: 64-year-old male with past medical history of diabetes mellitus type 2, cirrhosis, obstructive sleep apnea, and testicular cancer presented to pulmonology clinic after he was found to have an incidental lung mass on imaging. His only complaint was shortness of breath. Initial CT of the chest with and without contrast showed a new 3.5 cm x 1.6 cm lobulated soft tissue density mass in the superior segment of the left lower lobe concerning for malignancy. QuantiFERON and fungal serology panel were negative. Biopsy was recommended but deferred by patient. Repeat CT chest 2 months after the initial CT showed interval enlargement of the mass to 3.8 cm x 1.7 cm. Transthoracic needle biopsy was pursued but did not reveal any malignancy or granulomatous inflammation. Tissue GMS and AFB stains were negative. Bacterial and mycobacterial cultures did not grow any organisms, however, fungal cultures grew Cryptococcus neoformans. Subsequent serum cryptococcal antigen was elevated at 1:8. He was started on fluconazole and was found to have subjective improvement in his shortness of breath at his next follow-up appointment. Serum cryptococcal antigen performed one month after starting fluconazole trended up to 1:32 and subsequently decreased to 1:16 at two months. Unfortunately, he was subsequently lost follow-up due to health insurance and financial issues. DISCUSSION: Pulmonary cryptococcal infection often presents a challenging diagnosis for clinicians as it can present with nonspecific signs and symptoms such as dry cough, fever, malaise, dyspnea, and pleuritic chest pain [1]. Clinical manifestations range from asymptomatic infection to disseminated or fulminant disease. The diagnosis is more difficult to make by the fact that radiographic findings of cryptococcal pneumonia are often highly variable. The radiographic pattern can also vary depending on immune function and duration of disease. Furthermore, only about half of patients have findings on imaging [1]. The most common radiographic findings are pulmonary nodules or masses regardless of immune status [2]. Diffuse lung involvement, reticulonodular interstitial infiltrates, and pleural effusions are more common among immunocompromised hosts [2-3]. Cavitary lesions are more common in the immunosuppressed but have been noted to occur in immunocompetent individuals as well [2]. CONCLUSIONS: The clinical and radiographic presentation of cryptococcal pneumonia is highly variable. Clinicians should keep high suspicion and consider cryptococcoma within the differential diagnosis of pulmonary masses regardless of patient immune function. Reference #1: Skolnik K, Huston S, Mody CH. Cryptococcal Lung Infections. Clinics in Chest Medicine. 2017;38(3):451-464. https://doi.org/10.1016/j.ccm.2017.04.007. Reference #2: Khoury MB, Godwin JD, Ravin CE, Gallis HA, Halvorsen RA, Putman CE. Thoracic cryptococcosis: immunologic competence and radiologic appearance. AJR Am J Roentgenol 1984; 142: 893–6. Reference #3: Lacomis JM, Costello P, Vilchez R, Kusne S. The Radiology of Pulmonary Cryptococcosis in a Tertiary Medical Center. Journal of Thoracic Imaging. 2001;16(3):139-148. https://doi.org/10.1097/00005382-200107000-00001. DISCLOSURES: No relevant relationships by Mirza Ali, source=Web Response No relevant relationships by Johnathan Fagg, source=Web Response No relevant relationships by Mingchen Song, source=Web Response No relevant relationships by Saad Ullah, source=Web Response