Vol.2, No.9, 499-501 (2013) Case Reports in Clinical Medicine
Pulmonary cryptococcosis in an immunocompetent
patient—A case report
Fernando Morbeck*, Rafael Franco, Sergio Furlan, Marcos Duarte
Department of Radiology, Heliopolis Hospital, São Paulo, Brazil; *Correspondi ng A utho r: dr.fernandomorbeck@gmail.com
Received 23 October 2013; revised 20 November 2013; accepted 11 December 2013
Copyright © 2013 Fernando Morbeck et al. This is an open access article distributed under the Creative Commons Attribution Li-
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Cryptococcosis is an infection caused by fungi
that belong to the genus Cryptococcus. There
are several species of Cryptococcus, but two
species—Cryptococcus neoformans and Cry-
ptococcus gattii—cause nearly all cryptococcal
infections in humans. Cryptococcosis is one of
the most common fungal infections in Brazil and
becomes even more important after the onset of
the AIDS epidemic. The lung is the main gateway,
and also is the most common site, with diverse
clinical manifestations ranging from an asymp-
tomatic to severe pneumonia. When symptom-
matic, most patients present with fever and
cough with expectoration or hemoptysis. The
most common radiological findings in immuno-
competent patient s are located images of masses
and nodules, while immunosuppression shows
interstitial infiltrates and diffuses interstiti al op a-
city. This is a case report of a patient in the third
decade of life with breathing-dependent pain at
the base of the left hemithorax, who has radio-
logical examination of a mass in the left lung
base in contact with the pleura mimicking ma-
lignant lung. Lobectomy was performed, as well
as the p ath ological diagnosis of cry ptococcosis.
Keywords: Cryptococcosis; Pulmonary;
Immunocompetent; Fungal ; Lung Diseas e
Cryptococcosis (Busse-Buschke disease) is a fungal
disease caused by Cryptococcus neoformans and Crypto-
coccus gattii. The first is an opportunistic disease, cos-
mopolitan and conditions associated with immunosup-
pression cell. It occurs in various organic substrates, and
is usually rich in nitrogen source such as from bird feces.
Microfoci’s growth of this yeast is formed mainly in ur-
ban centers and related to pigeons. C. gattii is related to
infection of immunocompetent patients, being endemic
in tropical and subtropical areas. Its natural habitat pri-
marily is related to Eucalyptus camaldulensis plant re-
mains from Australia, but has been isolated from differ-
ent types of wood elsewhere in the world [1].
The mortality of the disease varies with the degree of
development of the country. In developed regions, the
rate is approximately 10% and around 43% in deve-
loping countries. In the Northeast and North regions of
Brazil, C. gatti infection of the central nervous system
has lethality of approximately 35% to 40%. In the South
Region, Southeast and Midwest, diseases secondary to C.
neoformans are prevalent because there is a higher rate
of AIDS [1].
Inhalation of dried yeasts causes natural infection,
causing an initial framework lung, which may progress
or regress depending on the host response. The clinical
picture may reach beyond the lung lesions, skin, bones,
adrenal, kidney and central nervous system, among
others [2].
Pulmonary infection is the most frequent, and the cli-
nical and radiological spectrum is quite broad. The im-
mune status of the patient plays an important role in this
range of signs and symptoms, and immunocompetent
patients tend to present with more self-limiting localized
lesions, since they are immunosuppressed with dissemi-
nation and respiratory failure. In one-third of cases, the
disease is asymptomatic. The symptoms are very non-
specific, predominantly fever and cough [3]. The in-
volvement of local lesions causes specific symptoms:
breathing-dependent pain (mass contact with the pleura)
and the upper lobes (mimics the Pancoast syndrome).
Furthermore, constitutional symptoms may be present,
with the union of clinical factorsradiologically indis-
tinguishable from malignant lung injury.
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F. Morbeck et al. / Case Reports in Clinical Medicine 2 (2013) 499-501
Unilateral or bilateral nodules are the most common,
and are rarely calcified or cavitary on radiological
examination. They generally stay on subpleural topogra-
phy with diameter ranging from 0.5 to 4.0 cm and are
characteristic of immunocompetent patients. Already,
immunosuppressed patients have interstitial infiltrates
and must always make the differential diagnosis with
pneumocystosis. There is also the miliary and hilar and
mediastinal lymphadenopathy similar to tuberculosis.
Pleural effusion is present in less than 10% of the cases
The diagnosis of an immunocompetent patient with
pulmonary involvement is usually done by biopsy or
surgical removal of the nodule with its histopathology. If
confirmed, there is a need to investigate infection of the
central nervous system via lumbar puncture.
The treatment of symptomatic patients with dissemi-
nated disease, positive cryptococcal antigen or immuno-
suppression should be performed with anti-fungal. How-
ever, those with localized, oligosymptomatic or asymp-
tomatic pulmonary forms or patients with resected pul-
monary nodules [1] can be accompanied by rigorous
clinical and laboratory monitoring. The surgery for re-
section of the lesion is performed in specific cases such
as pseudotumor injuries and not responsive to medical
treatment, and extensive exudative pleural effusion.
A 36-year-old african american woman with no sig-
nificant past medical history was attended at Heliopolis
Hospital Emergency Room (Sao Paulo – Brazil) due to a
breathing-dependent pain in the left hemithorax from one
week. Five days prior, the patient sought another service
being prescribed antibiotic therapy, but there was no im-
provement. The physical examination revealed decreased
breath sounds in the lower third of the left hemithorax
and vital signs unchanged.
During the diagnostic investigation, the patient had
hemoglobin of 10.5 mg/dL, white blood cell 8720 mg/dL,
C-reactive protein 6.1 mg/dL, and the HIV virus search
was negative.
Chest radiograph (Figures 1 and 2) presents extensive
opacity in the lower third of the left hemithorax in the
posterior region. The patient was admitted for investiga-
Computed tomography (Figure 3) showed low atte-
nuation mass, heterogeneous, suggesting areas of necro-
sis in the lower lobe in lateral and posterior basal seg-
ment associated with ipsilateral pleural effusion.
A thoracentesis was performed, looking bloody, with
blood glucose of 116 mg/dL, LDH 838 U/L, albumin 3.8
g/dL, amylase 36 U/L and negative culture in the first
sample. The cytology was negative. A second thoracen-
tesis was attempted, but not enough liq uid was evidenced
Figure 1. Chest X-ray.
Figure 2. Chest X-ray.
Figure 3. Computerized Tomography (CT).
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F. Morbeck et al. / Case Reports in Clinical Medicine 2 (2013) 499-501
Copyright © 2013 SciRes. OPEN ACCESS
differential diagnosis with infection, infarction, and ab-
scess should be performed. The use of PET/CT has an
indeterminate finding, because both malignancies such as
infection and inflammation are often hypermetabolic.
These findings cause many false positives in endemic
areas [5]. Surgical treatment should not be the first op-
tion in cases of cryptococcal infection. However, when it
does not respond adequately to drug therapy, a resection
of the lesion (usually a lobectomy) should be performed.
by ultrasound.
Diagnostic option was surgical resection of the tumor
which, under direct visualization, had hardened aspect
and was adhered to the chest wall and diaphragm. A
lobectomy was performed. The pathological analysis was
positive for cryptococcal infection (Figur e 4).
Cryptococcal infection presents an increased preva-
lence in patients with immunosuppression of T cells. The
male is the most affected. In patients with HIV, the ra-
diological pattern is a predomin ant interstitial infiltration,
alveolar infiltrates, mixed infiltrate and pleural effusion.
A less common finding is excavation. Immunocompetent
individuals, such as the patient in question, present with
nodular lesions or masses [1,4]. Other cases of immuno-
competent patients reported in the literature showed the
same image aspect, however, clinical history was vari-
able [4,6,7].
This report reinforces the importance of pseudotu-
moral lesions for the differential diagnosis of lung
masses by radiologists, pulmonologists and oncologists.
[1] Kon, A.S., Grumach, A.S. and Colombo, A.L., et al. (2008)
Guidelines in cryptococcosis. Revista da Sociedade Bra-
sileira de Medicina Tropical, 41, 524-544.
[2] Patz Jr., E.F. and Goodman, P. C. (1992) Pulmonary cryp-
tococcosis. Journal of Thoracic Imaging, 7, 51-55.
Regarding the aspect of injury, the lung mass with ir-
regular delimited contours, more prevalent in radiology,
is often associated with close contact with the pleural
surface. Pulmonary nodules also exhibit irregular defined
contours [4,5]. Involvement is most often unilateral. A
study of 14 patients with a diagnosis of pulmonary cry-
ptococcosis confirmed by cytological and histological
investigation showed that 64.2% of the lesions had the
mass aspect and 50% had contact with the pleura [4].
[3] Severo, C.B., Gazzoni, A.F. and Severo, L.C. (2009) Pul-
monary cryptococcosis. Jornal Brasileiro de Pneumologia,
35, 1136-1144.
[4] Silva, A.C.G., Marchiori, E., Souza Jr., A. and Irion, K.L.
(2003) Criptococose pulmonar: Aspectos na tomografia
computadorizada. Radiologia Brasileira, 36, 277-282.
[5] Guimarães, M.D., Marchiori, E., Meirelles, G.S.P., et al.
(2013) Fungal infection mimicking pulmonary malign-
nancy: Clinical and radiological characteristics. Lung, in
press. http://dx.doi.org/10.1007/s00408-013-9506-0
The radiological finding of an extensive lesion in the
lung with irregular contours suggests malignancy, but the
[6] Fong, I.A., Glória, C., Mesquita, I. and Diogo, N. (1999)
Pulmonary cryptococcosis in an immunocompetent pa-
tient. A case report and a review. Revista Portuguesa de
Pneumologia, 4, 419-426.
[7] Barbosa, A.T.F., Colares, F.A., Gusmão, E.S., Barros,
A.A., Cordeiro, C.G. and Andrade, M.C.T. (2006) Iso-
lated pulmonary cryptococcosis in an immunocompetent
patient. Jornal Brasileiro de Pneumologia, 32, 470-480.
Figure 4. (A) Histological examination with hematoxylin and
eosin showed the presence of spore (arrow). (B) Mucicarmine
staining (arrow) confirmed the diagnosis of Cryptococcus.