PULMONARY CRYPTOCOCCOSIS MASQUERADING AS LYMPHOMA

Abstract

SESSION TITLE: Pulmonary SESSION TYPE: Global Case Reports PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM INTRODUCTION: Pulmonary cryptococcosis (PC) is an uncommonly diagnosed disorder. We describe a unique case of PC presenting as lymphadenopathy, diagnosed by endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) technique. CASE PRESENTATION: 58-year-old, never smoker, male with follicular lymphoma (status post completion of 6 cycles of R-CHOP (Rituximab, Cyclophosphamide, Vincristine, Doxorubicin)) was referred to for evaluation of new positron emission tomography/computed tomography (PET/CT) avid right hilar adenopathy, and left upper lobe nodular opacity. His review of systems was positive for mild shortness of breath on exertion; and an unremarkable physical exam. Laboratory studies were significant for lactate dehydrogenase level of 283, and no preceding neutropenia or lymphopenia. Significant interval history included hemophillus influenza pneumoni Patient underwent a EBUS-TBNA of the right hilar lymph node. Cytology was negative for malignant cells but showed intracellular yeast in histiocytes; the tissue culture was positive for Cryptococcus neoformans. Patient was started on fluconazole and CT of the chest done 2 months after treatment initiation, showed no evidence of hilar lymphadenopathy. DISCUSSION: PC is an uncommonly diagnosed disorder and seen in less than 4% of patients diagnosed with cryptococcosis. Common predisposing factors include AIDS, chronic corticosteroid use, and solid organ-transplants. Most common radiographic presentation is single or multiple, small, peripherally distributed, upper and middle lung zone predominant, pulmonary nodules and bilateral airspace consolidation. In studies by Li-Xuan et al and Chang et al, radiographic presentation of PC was compared amongst immunocompromised and immunocompetent host, pulmonary nodules were the most common finding and associated cavitation were more frequently seen in immunocompromised patients. In a study done by Lacomis et al, patients with HIV, solid organ transplant and non-HIV, non-solid organ transplants were looked at; lymph node enlargement was uncommon in all the groups but more commonly found in the HIV group and was always less than 1.5cm. SCrAg is positive in 71% of patients with disseminated disease; however only positive in 21% of patients with pulmonary disease alone. Cultures grown from biologic samples is the Gold standard test for diagnosis of cryptococosis9. In 2016, Schmalzle et al11, looked at 583 patients with malignancy with culture results positive for cryptococcus and found that 83% of patients had hematologic malignancy. Pulmonary disease was also more commonly seen in patients with hematologic malignancies and in these case cryptococcal antigen was negative in majority of the patients. CONCLUSIONS: Cryptococcal lymphadenitis should be considered in the differential diagnosis in an immunocompromised patient presenting with lymphadenopathy despite a negative serum cryptococcal antigen. Reference #1: Chang, Wei-Chou et al. “Pulmonary Cryptococcosis.” CHEST , Volume 129 , Issue 2 , 333 – 340. Reference #2: Chichra A, Lama KW, Koenig SJ. Respiratory failure with hilar mass: Role of endobronchial ultrasound-guided transbronchial needle aspiration in the medical intensive care unit. Lung India : Official Organ of Indian Chest Society. 2015;32(2):178-181. Reference #3: Li-Xuan, Xie. “Pulmonary Cryptococcosis: Comparison of Clinical and Radiographic Characteristics in Immunocompetent and Immunocompromised Patients.” Chest, Elsevier, 23 Dec. 2015. DISCLOSURES: No relevant relationships by Robert Lee, source=Web Response No relevant relationships by Priyanka Makkar, source=Web Response No relevant relationships by Carlie Sigel, source=Web Response No relevant relationships by Jonathan Vaucher, source=Web Response