Pulmonary cryptococcosis with cryptococcal meningitis in an immunocompetent host
In September, 2010, a 36-year-old man was referred to our service for evaluation of a suspected lung cancer. He complained of dull aching pain on left anterior chest, cough with scanty sputum, loss of appetite and weight for 6 weeks. He had no fever, hemoptysis, abdominal, or neurological symptoms at presentation. He denied any preexisting lung disease, diabetes, illicit drug abuse or intake of immunosuppressive agents. He was a mason by profession and had smoked for 10 pack-years. He lives in a village in Tamil Nadu, India and had never traveled away from his native state. General physical examination was unremarkable. Chest examination revealed a dull percussion note with diminished breath sound on left hemithorax. Chest radiograph showed a large mass in the left lung []. He was hospitalized for workup of a possible lung cancer. Leukocyte count was 22,500/mm3 with a predominance of neutrophils. Serum electrolytes, liver and renal functions were normal. Serology for human immunodeficiency virus (HIV) was negative. Serum immunoglobulin levels and CD4 count (618 cells/μL) were normal. Chest computed tomography (CT) scan confirmed a large mass (11.9 cm × 8.2 cm) in left upper lobe (LUL) with central hypoattenuation []. On 3rd day of hospitalization, patient developed mild headache and nausea. He was awake-alert and had no neck rigidity or focal neurological deficit. Considering the possibility of meningitis or cerebral metastasis, immediate contrast enhanced CT brain was performed that showed mild meningeal enhancement with normal ventricles and brain parenchyma. CT guided fine needle aspiration cytology (FNAC) of the lung mass showed numerous budding yeasts resembling Cryptococcus and no evidence of malignancy. Lumbar puncture following neurologist opinion revealed clear cerebrospinal fluid (CSF) under normal pressure with pleocytosis (leukocytes 16 cells/μL, 100% lymphocytes) and stained positive for India ink preparation. Serum and CSF were positive for cryptococcal antigen by latex agglutination test. However, culture for the fungus was negative in CSF and blood. Staining for acid fast bacilli was negative in sputum, CSF and bronchial wash. Flexible bronchoscopy showed a whitish-yellow mass in LUL bronchus. Bronchial washings and endobronchial biopsy were consistent with cryptococcal infection []. He was treated with Inj. amphotericin B 50 mg/day (1 mg/kg/day) and flucytosine 4 g/day orally (in four divided doses) for initial 4 weeks. He had remarkable clinical and radiological improvement after completion of induction therapy. His renal function and leukocyte count remained normal throughout the course of therapy. Therapy was switched to oral fluconazole 400 mg/day for 8 weeks followed by 200 mg/day continued until November 2011. Complete resolution of the mass was ensured in follow-up imaging [] and he was well until last contact in March 2012.