Isolated cavitary lung disease in a renal allograft recipient: A rare manifestation of cryptococcus
A 38-year-old male, carpenter by occupation received renal allograft in 2004 for end stage renal disease due to chronic glomerulonephritis. The renal donor was his mother. He was not given induction therapy. He received triple drug immunosuppression that included prednisolone, mycophenolate mofetil, and tacrolimus in therapeutic doses. Mycophenolate mofetil was replaced with azathioprine after 3 months due to financial constraints. He maintained good graft function.\nAfter 8 years of renal transplantation, he presented with non-pleuritic chest pain on the right side and breathlessness of 2 days duration. There was no history of fever, cough, or hemoptysis.\nThe examination was essentially, unremarkable except for an area of bronchial breathing over his right mammary region. His hemogram showed hemoglobin of 10.5 g/dL, and normal total and differential leukocyte and platelet counts. Urine examination was normal. The blood urea and serum creatinine were 50 mg/dL and 1.5 mg/dL respectively. The liver function tests were within normal limits. His HBsAg, anti-hepatitis-C virus, anti-human immune deficiency virus, cytomegalovirus IgM antibodies tests were negative. Chest X-ray revealed right mid-zone cavitary lesion with a fluid level []. High resolution computerized tomography showed area of cavitation with nodular density and fibrotic bands suggesting infective pathology.\nBronchoscopy revealed multiple small papillomatous nodules in the tracheobronchial tree. Bronchoalveolar lavage (BAL) was negative for microbial gram stain and culture, nocardia, acid fast bacilli, pneumocystis jiroveci, and malignant cells. Endobronchial biopsy showed pseudostratified ciliated columnar epithelium with squamous metaplasia. Spores of cryptococcus were seen in focal areas in the epithelium. Periodic acid-Schiff stain highlighted the fungus spores []. Although, clinically, there were no signs and symptoms of meningitis, cerebrospinal fluid analysis was done and it was negative for cryptococcal meningitis. He was treated with fluconazole 200 mg twice a day for 6 months and the dose of tacrolimus was decreased keeping the blood tacrolimus levels in the therapeutic range and showed clinical and radiological improvement []. Before starting fluconazole, he was receiving tacrolimum 2 mg twice a day that had to be decreased to 0.5 mg twice a day.