Pulmonary Cryptococcosis presenting as military tuberculosis in an immunocompetent patient. Joshi S, Tayal N, Gupta R, Bhatia A, Kapoor N. J Assoc Chest Physicians 2021;9:29-31

Post Date: November 24, 2021

Cryptococcal infections are caused by the fungi Cryptococcus gattii and C. neoformans commonly found in, soil, bird droppings and decaying wood.[1] It is mostly found in immune compromised patients and is acquired by inhalation of aerosolized particles.[2] In immunocompetent host Cryptococcus usually remain as a commensal in tracheobronchial tree.[3] The most common radiographic findings in the immunocompetent host are single or multiple predominant peripheral based nodules.[4] We are here presenting a case of pulmonary cryptococcosis in an immunocompetent young male which is a rare clinical entity.

A 38 years male, farmer by occupation was admitted with complaints of high-grade fever (Upto 105 F), dry cough and breathlessness for 20 days. Patient did not have history of any chronic disease. He was given Anti tubercular treatment at another hospital on clinicoradiologial basis. On arrival in emergency, patient was conscious and oriented. His vital parameters were heart rate − 120/min, blood pressure − 120/80mm Hg, respiratory rate − 32/min, oxygen saturation − 88% on Rebreather Mask with Oxygen at the rate of 15 litres(L)/minute(min), body temperature 101 F. Systemic examination was normal except bilateral crepitations on chest auscultation. His Arterial Blood Gas analysis showed Hypoxemic respiratory failure (pH 7.464, PCO2-36.9, PO2-52.7, Hco3-26.1).

His blood investigations showed Haemoglobin: 11.1 g/dl, Total leucocyte count: 4540/cmm, platelet: 2,82,000/cumm, Serum Procalcitonin-1.22 IU, normal Kidney function test and Liver function test. Blood tests for Malaria (Peripheral Blood Film and Malaria Antigen test) and typhi dot were negative. His Chest X Ray showed bilateral nodular opacities in all zones [Figure 1]. His CT thorax showed extensive diffuse peribronchovascular thickening with nodularity in bilateral lungs. Bilaterally symmetrical dependant posterior consolidation like changes and areas of ground glass opacity in lower and peripheral aspects on both sides [Figure 2]. As the patient continued to be febrile and all microbiological investigations were normal(Sputum Acid fast bacilli smear negative, pyogenic culture negative), Fibreoptic Bronchoscopy was done [Figure 3]. Bronchoalveolar lavage(BAL) and Transbronchial Lung biopsy (TBLB) was taken. Histopathology of TBLB [Figure 4] showed a few round to oval encapsulated yeast-like fungal structures. The Fungal structures identified on H&E stain were positive for PAS and Methenamine staining suggestive of cryptococcal infection. BAL sent for microbiological investigations did not show any bacterial infection. So a diagnosis of Cryptococcal pneumonia was made. Treatment with Antifungal medication (Liposomal Amphotericin) was started. Patient’s condition improved dramatically. He became afebrile within next 12 hours and could maintain oxygen saturation of 90% on oxygen supplementation through Face Mask at a flow of 5 L/min. We treated with Amphotericin B (150 mg/day infusion) for 2 weeks followed by Oral Fluconazole 400 mg/day for 10 weeks.