UNILATERAL EXUDATIVE PLEURAL EFFUSION DUE TO CRYPTOCOCCAL INFECTION IN AN IMMUNOCOMPETENT INDIVIDUAL

Abstract

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pleural effusion, which can be exudative or transudative as per Light's criteria and has more than 50 recognized cases. It occurs as a result of increased fluid formation and /or reduced fluid resorption. Exudative effusion can be caused by malignancy, tuberculosis, PE, rheumatoid arthritis, pancreatitis, and rarely fungal infections. Cryptococcal infection causing pleural effusion is extremely rare with just 50 reported cases and that too in immunocompromised patients with reduced cellular function. [1]Pulmonary Cryptococcus is seen in immunocompromised patients with reduced cellular function and pleural presentation is rarely seen in pulmonary cryptococcosis. We are presenting a unique case in which this disease was found in an immunocompromised person. CASE PRESENTATION: Our patient is a 58 year old Male who had gone for Pre-op check up for his shoulder surgery where routine chest x-ray showed left sided pleural effusion. On presentation, he denied any complaints of dyspnea, chest pain, or fever. He is a non smoker, works in a plasma center and lives in a basement apartment complex. He further denied owning any pets or any outdoor hobbies such as hiking, camping, or canoeing. Auscultation of chest revealed reduced air entry on left side. Labs works showed serum cryptococcal antigen positive. Rest of the investigations were normal . The patient underwent thoracocentesis which drained out 1200 ml of green colored fluid which was sent for gram stain, AFB stain and culture sensitivity and were negative. Sputum and CSF analysis were negative as well. He was started on Amphotericin B and Fluconazole IV for 2 weeks as induction therapy following which patient improved clinically. Patient was discharged with continuation of consolidation therapy with fluconazole for 8 weeks on outpatient basis. He was followed up at the clinic where Chest X ray showed resolution of the infection. DISCUSSION: Pulmonary cryptococcus is an opportunistic infection usually seen in immunocompromised patients like those with HIV infection, hematological malignancies, immunosuppressive medications etc. Pleural effusion is rare presentation of pulmonary cryptococcus and even rarer in an immunocompetent individual. Only 35% of cases with pulmonary cryptococcal infection were in immunocompetent people and most of them were reported in Asia. Patients with immunocompetent state with cryptococcal infection usually showed pneumonia like manifestations or solitary and well defined nodules. Our case did not show any manifestations other than the pleural effusion. Cryptococcal Antigen(CrAg) testing in body fluids can guide us for confirmation of the disease. 56% of patients with Non HIV related Cryptococcal infection tested positive for CrAg. CONCLUSIONS: This Unique case shows that cryptococcal infection can present in immunocompetent person. That this case was found in North America with no risk factors in the person. REFERENCE #1: [1] Hooper C, Lee YCG, Maskell N Investigation of a unilateral pleural effusion in adults: British Thoracic Society pleural disease guideline 2010Thorax 2010;65:ii4-ii17. REFERENCE #2: Shirley RM, and Baddley JW. 2009. Cryptococcal lung disease. Curr. Opin. Pulm. Med. 15(3):254–260 REFERENCE #3: Zhang Y, Li N, Zhang Y, Li H, Chen X, Wang S, Zhang X, Zhang R, Xu J, Shi J, Yung RC. Clinical analysis of 76 patients pathologically diagnosed with pulmonary cryptococcosis. Eur Respir J. 2012;40:1191-1200Ye F, Xie JX, Zeng QS, Chen GQ, Zhong SQ, Zhong NS. Retrospective analysis of 76 Immunocompetent patients with primary pulmonary cryptococcosis. Lung. 2012;190:339-346. DISCLOSURES: No relevant relationships by Farhan Ali, source=Web Response No relevant relationships by Sucheta Kundu, source=Web Response