SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Cryptococcal pulmonary nodule in an immunocompetent individual is rare. Here, we perform a literature review on management of asymptomatic pulmonary cryptococcus detected incidentally on radiological imaging. CASE PRESENTATION: An 80-year-old African American male with past medical history of stage II prostate cancer and hypertension presented to our hospital with subacute onset of bilateral lower limb weakness. Extensive workup was inconclusive for etiological diagnosis but showed an incidental 1.2 x 0.9 cm spiculated left upper lobe nodular density on CT chest. Biopsy of the lesion was performed to determine cause and to rule out paraneoplastic syndrome. Cytology was negative for malignant cells but, in fact showed localized granulomatous reaction with fungal forms consistent with Cryptococcus. Serum and CSF were negative for Cryptococcal antigen. He was HIV negative and had no respiratory symptoms. Treatment with fluconazole 400 mg once a day was initiated. DISCUSSION: Cryptococcosis is a potentially life-threatening fungal infection typically caused by inhalation of spores of C. neoformans or C. gatti. Most cryptococcal infection in immunocompetent patients are detected due to radiological shadows. Rarely, they may present as spiculated lesion mimicking lung cancer, as seen in our patient.1,2 The most common radiological findings in immunocompetent pulmonary cryptococcosis are patchy consolidation and solitary nodularity1. Other radiological findings include cavitation, multinodular opacity, pleural effusion, mediastinal lymphadenopathy, and lobulated lesions. Per IDSA guidelines, asymptomatic immunocompetent patients with positive Cryptococcus lung culture may be observed carefully or treated with fluconazole 200-400 mg/day for 3-6 months3. Immunocompetent patients presenting with mild-to-moderate symptoms should be treated with fluconazole 200-400 mg/day for 6-12 months3. Alternative regimens include itraconazole and amphotericin B. Regardless of the treatment chosen, all patients should have a lumbar puncture to rule out concomitant CNS infection. Medication should be administered for about 6-12 months or until the radiological shadows disappear completely, fiberize, or calcify. Surgical intervention should be considered when the lung lesions remain stable or enlarge following 3–6 months of standard antifungal treatment or when the lesions are difficult to differentiate from tumors1. CONCLUSIONS: We decided to treat our patient with fluconazole due to evidence of reduced morbidity and mortality and prevention of progression to potential life-threatening CNS disease. However, there are possible drawbacks of therapeutic intervention including drug related toxicities and interactions, cost of drug and monthly monitoring. Thus, mutual decision making between the patient and physician is required. We plan to repeat CT chest in 3 months to reassess lung mass. Reference #1: Feng Ye, Jia-xing Xie, Qing-si Zeng et al. Retrospective analysis of 76 immunocompetent patients with primary pulmonary cryptococcosis. Lung. 2012;190:339–346. Reference #2: Kaixiong Liu, Haibo Ding, Bing Xu et al. Clinical analysis of non-AIDS patients pathologically diagnosed with pulmonary cryptococcosis. Journal of thoracic disease. 2016;8(10):2813-2821. Reference #3: Michael S. Saag, Richard J. Graybill, Robert A. Larsen et al. Practice guidelines for the management of cryptococcal disease. Clinical Infectious Diseases. 2000; 30:710-18. DISCLOSURES: No relevant relationships by Ipsa Arora, source=Web Response No relevant relationships by Kanishk Sharma, source=Web Response No relevant relationships by Sami Tahhan, source=Web Response