Pleural Effusion as the Initial Clinical Presentation in Pulmonary Cryptococcosis: A Report of a Case with Unusual Manifestation, and a Literature Review

Abstract

The diagnosis of the pulmonary cryptococcosis is relatively difficult. This is due to its nonspecific symptoms and usually negative culture results, the low sensitivity of the serum cryptococcal antigen test, and the wide variety of radiological appearances. Although immunocompromised patients are at the highest risk, it may occur in patients with normal immunity. In immunocompetent patients with pulmonary cryptococcosis, several radiographic patterns are exhibited, including pulmonary nodules, interstitial infiltrations, and consolidation. Pleural effusion rarely occurs in immunocompetent patients. This patient was a victim of pulmonary tuberculosis (TB) complicated with pleural effusion and chest wall involvement. After complete anti-TB treatment, the pleural effusion disappeared. Unfortunately, 2 years later, right-side pleural effusion recurred and a loss of body weight was also noted. The initial impressions were 1, pulmonary TB reactivation complicated with pleural effusion; and 2, adenocarcinoma of the lung with pleural effusion. Sono-guided thoracocentesis was performed. Cytology examinations of the pleural fluid showed highly suspected cryptococcus infection, but the cryptococcal antigen test showed negative. He underwent a video-assisted thoracoscopic decortication for further diagnosis, and treatment for fibrothorax. The pathology of the tissue from decortication showed yeast-like microorganisms. Due to the renal impairment after amphotericin B treatment, he received fluconazole therapy, and regularly followed up in the outpatient department. After antifungus treatment, he gained weight and felt better than before. Based on this unusual presentation of cryptococcosis, physicians should consider the possibility of cryptococcosis of the lung complicated with pleural effusion in the differential diagnosis of chronic pleural effusion in Taiwan.