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Chest clinic
Images in Thorax
Cryptic clues for an infection puzzle: from inside out
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  1. Ding-Jie Lee1,
  2. Hung-Hui Liu2,
  3. Dun-Wei Huang3,
  4. Chia-Hua Lin4,
  5. Chung-Kan Peng5
  1. 1 Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
  2. 2 Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
  3. 3 Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
  4. 4 Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
  5. 5 Division of Pulmonary Medicine and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
  1. Correspondence to Dr Chung-Kan Peng, Division of Pulmonary Medicine and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan; kanpeng{at}mail.ndmctsgh.edu.tw

https://doi.org/10.1136/thoraxjnl-2018-212653

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    A 60-year-old male farmer with headache without fever for 2 months and with no other systemic disease presented to the emergency department with a 2-week history of non-productive cough as well as progressive hearing and vision loss. Chest radiography and CT scan revealed a left solitary tumour with pleural attachment (figure 1) without associated lymphadenopathy. At 3 days after admission, he lost consciousness and was administered emergency endotracheal intubation. On physical examination, a crusted nodule was observed proximal to the lateral end of the left eyebrow (figure 2). CT scan of the head revealed multiple foci of ischaemic change. An India ink stain of the cerebrospinal fluid (CSF) showed multiple encapsulated round yeasts. Biopsies of the nodule (figure 3) and the pulmonary tumour confirmed cryptococcoma. Additional laboratory tests revealed an elevated serum cryptococcal antigen titre (1:32) and normal blood CD4 +T cell count (471/m3). Moreover, viral examinations (for the serum HIV antibody and other viruses) as well as autoimmune panels were all negative. Furthermore, Cryptococcus gattii grew in all fungus cultures of the nodule, lung tumour and CSF. Fluconazole was administered as the main therapy for 3 weeks.

    Figure 1
    Figure 1

    Axial chest CT showing left solitary tumour with pleural attachment.

    Figure 2
    Figure 2

    A crusted nodule proximal to the tail of left eyebrow.

    Figure 3
    Figure 3

    Periodic acid–Schiff stain (original magnification ×200) showing multiple encapsulated round yeasts (arrow) with lymphatic invasion (arrowhead).

    Discussion

    C. gattii is more prevalent than C. neoformans in immunocompetent hosts.1 The infection might manifest as cryptococcoma mimicking lung cancer.2 Moreover, it could be misdiagnosed as stroke because of severe neurological deficits, such as hearing loss or blindness.3 This infection rarely presents with cutaneous cryptococcal nodules, as observed in the present case, and merits extensive evaluation of disseminated cryptococcal infection involving, in particular, the lung and brain.

    References

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      . Pulmonary cryptococcosis mimicking solitary lung cancer in an immunocompetent patient. Thorax 2008;63:478–478.doi:10.1136/thx.2007.079244
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      . Cryptococcal meningitis (C. neoformans var. gattii) leading to blindness in previously healthy Melanesian adults in Papua New Guinea. Q J Med 1994;87:343–9.
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    Footnotes

    • Contributors D-JL and C-KP managed the patient. H-HL and D-WH performed the surgery. C-HL prepared the image and D-JL prepared the manuscript. C-KP revised this article.

    • Competing interests None declared.

    • Patient consent for publication Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.