Lung Masses as a Presenting Sign of Disseminated Cryptococcus.

Savannah Tan,George Nasr,Cameron Harding

doi:10.7759/cureus.15185

Abstract

Cryptococcosis is an invasive fungal disease that most commonly affects immunocompromised individuals, typically causing pulmonary and central nervous system (CNS) symptoms. The fungus that causes cryptococcosis, Cryptococcus, is globally disseminated and often transmitted through bird droppings. The two most frequent and pertinent species responsible for clinical infections in humans include Cryptococcus neoformans, which has been known to cause the majority of cryptococcosis globally until recently, during which Cryptococcus gattii has been identified and reported more frequently.A 54-year-old male with a history of renal transplant on chronic immunosuppressants and type 2 diabetes mellitus was found to have multiple lung masses within the right upper and right lower lobes. He had also been experiencing syncope, multiple falls, worsening headaches, tinnitus, diplopia, and ongoing weight loss. The patient underwent a percutaneous biopsy of one of the lung masses in addition to a lumbar puncture (LP), both of which revealed positive cryptococcus antigen confirmed to be C. gattii. The patient was started on amphotericin B and flucytosine to treat cryptococcal meningitis. Despite treatment, his condition continued to worsen, necessitating daily therapeutic LP and temporary placement of a lumbar drain. Once his symptoms were better managed, he was discharged from the hospital but has continued to have serial LPs outpatient while concurrently taking fluconazole to prevent reaccumulation of cerebrospinal fluid (CSF) and recurrence of symptoms. This report describes a unique presentation of disseminated C. gattii infection presenting as multiple lung masses and the subsequent management of CNS cryptococcosis.

Highlights

Cryptococcus is a type of invasive fungus found in the soil worldwide and is often transmitted through bird droppings
Numerous studies have shown that C. neoformans grows quickly in the brain and more commonly manifests with meningitis or meningoencephalitis while C. gattii infection customarily presents as a pulmonary disease because of its ability to grow faster in the lungs [6]
According to the Infectious Diseases Society of America (IDSA), central nervous system (CNS) and disseminated disease with large and multiple cryptococcomas caused by C. gattii infection should be treated with a combination of amphotericin B and flucytosine therapy for four to six weeks, followed by fluconazole for six to 18 months, depending on

Summary

Introduction

Cryptococcus is a type of invasive fungus found in the soil worldwide and is often transmitted through bird droppings. He initially presented to the emergency department as trauma after a syncopal episode with brief loss of consciousness and was evaluated with a full workup that included a chest x-ray, which incidentally demonstrated round opacities in the right lower lung. CT of the chest was ordered to investigate further, and the patient was found to have pulmonary masses within the right upper and right lower lobes, the largest being 6.5 cm in the right upper lobe, concerning post-transplant malignancy such as primary bronchogenic carcinoma (Figure 2) At the time, he had been experiencing multiple syncopal episodes and falls with worsening headache, tinnitus, diplopia, and ongoing weight loss. The lumbar drain was removed following lower drainage rates His most recent chest CT, two months after initial presentation, showed continued consolidative opacities in the peripheral right lung consistent with cryptococcal infection, without significant change in size (Figures 3, 4). The patient’s mental and neurological status is back to baseline with plans to follow-up with neurosurgery, infectious disease, and nephrology

Discussion

Conclusions

Disclosures

Pappas PG