- Email: [email protected]
Mediastinal Cryptococcoma in an Immunocompetent Host
Chest Infections SESSION TITLE: Fungal Infections 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM
Mediastinal Cryptococcoma in an Immunocompetent Host Jie Qu* and Elie Berbari Mayo Clinic, Rochester, MN INTRODUCTION: Cryptococcal infection typically occurs in patients with T-cell mediated immune defects such as in acquired immunodeficiency syndrome, transplant-related immunosuppression, or hematologic malignancies. We describe a rare presentation of a superinfected mediastinal cryptococcoma in a young immunocompetent patient. CASE PRESENTATION: A 26-year-old previously healthy female presented with acute onset of fever, shortness of breath, and pleuritic chest pain. She denied any sick contacts, animal exposures, recent travels or smoking history. She works as a dental assistant and her yearly Tuberculin Skin Test has been negative. On presentation, she was febrile at 39.2 degrees Celsius and tachycardic with pulse 111 beats/min. Initial laboratories were notable for elevated leukocytes count at 22.2 (3.5-10.5x109/L), CRP at 46.4 (nl<8.0mg/L), and BNP at 371 (5-140pg/ml). A Chest X ray revealed a right upper lobe lung mass. A chest computed tomography demonstrated a 6.3 x 6.8 x 6.3 centimeter right paratracheal mediastinal mass with chunky internal calcification as well as a circumferential pericardial effusion. Bronchoscopy with transbronchial needle aspiration demonstrated frankly purulent caseous material. GMS stain of the aspirate was negative. Cytology and biopsy showed mixed inflammation with amorphous debris with no evidence of malignancy. Serum beta-HCG, AFP, LDH were all within normal limits. The patient was started on parenteral vancomycin and piperacillin/tazobactam. A transthoracic echocardiogram demonstrated a moderate to large circumferential pericardial effusion. Pericardiocentesis was performed and analysis of the pericardial fluid demonstrated 2992 total nucleated cells (52% neutrophils, 21% lymphocytes). Cytology was negative for malignancy but showed mixed inflammation. Fungal culture from bronchial washings grew Cryptococcus neoformans, and the paratracheal aspirate grew Streptococcus mitis. HIV serology was negative. Immunoglobulins and CD4 count were within normal limits. Patient was discharged on a 6-month course of oral fluconazole and 4-week course of parenteral ertapenem with improvement of her respiratory symptoms.
CONCLUSIONS: Although some cases of pulmonary cryptococcosis resolve without treatment, in our patient, due her large mediastinal mass burden, pericardial involvement, and superinfection with Streptococcus mitis, treatment was pursued with both antibacterial and antifungal therapies with subsequent improvement. Reference #1: PMID: 16478849 Reference #2: PMID: 14665493 Reference #3: PMID: 28275498 DISCLOSURE: The following authors have nothing to disclose: Jie Qu, Elie Berbari No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2017.08.172
Copyright ª 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
chestjournal.org
141A
CHEST INFECTIONS
DISCUSSION: Cryptococcus neoformans is an encapsulated yeast commonly found in soil, pigeon excreta, chickens, and decayed wood. Cryptococcus neoformans commonly infects immunocompromised hosts. We present a rare case of mediastinal cryptococcoma, superinfected with Streptococcus mitis, in an immunocompetent patient. Infection in immunocompetent patients typically manifest as pulmonary nodules, either multiple or solitary, lymphadenopathy, consolidation, or cavitation.
Mediastinal Cryptococcoma in an Immunocompetent Host Jie Qu* and Elie Berbari Mayo Clinic, Rochester, MN INTRODUCTION: Cryptococcal infection typically occurs in patients with T-cell mediated immune defects such as in acquired immunodeficiency syndrome, transplant-related immunosuppression, or hematologic malignancies. We describe a rare presentation of a superinfected mediastinal cryptococcoma in a young immunocompetent patient. CASE PRESENTATION: A 26-year-old previously healthy female presented with acute onset of fever, shortness of breath, and pleuritic chest pain. She denied any sick contacts, animal exposures, recent travels or smoking history. She works as a dental assistant and her yearly Tuberculin Skin Test has been negative. On presentation, she was febrile at 39.2 degrees Celsius and tachycardic with pulse 111 beats/min. Initial laboratories were notable for elevated leukocytes count at 22.2 (3.5-10.5x109/L), CRP at 46.4 (nl<8.0mg/L), and BNP at 371 (5-140pg/ml). A Chest X ray revealed a right upper lobe lung mass. A chest computed tomography demonstrated a 6.3 x 6.8 x 6.3 centimeter right paratracheal mediastinal mass with chunky internal calcification as well as a circumferential pericardial effusion. Bronchoscopy with transbronchial needle aspiration demonstrated frankly purulent caseous material. GMS stain of the aspirate was negative. Cytology and biopsy showed mixed inflammation with amorphous debris with no evidence of malignancy. Serum beta-HCG, AFP, LDH were all within normal limits. The patient was started on parenteral vancomycin and piperacillin/tazobactam. A transthoracic echocardiogram demonstrated a moderate to large circumferential pericardial effusion. Pericardiocentesis was performed and analysis of the pericardial fluid demonstrated 2992 total nucleated cells (52% neutrophils, 21% lymphocytes). Cytology was negative for malignancy but showed mixed inflammation. Fungal culture from bronchial washings grew Cryptococcus neoformans, and the paratracheal aspirate grew Streptococcus mitis. HIV serology was negative. Immunoglobulins and CD4 count were within normal limits. Patient was discharged on a 6-month course of oral fluconazole and 4-week course of parenteral ertapenem with improvement of her respiratory symptoms.
CONCLUSIONS: Although some cases of pulmonary cryptococcosis resolve without treatment, in our patient, due her large mediastinal mass burden, pericardial involvement, and superinfection with Streptococcus mitis, treatment was pursued with both antibacterial and antifungal therapies with subsequent improvement. Reference #1: PMID: 16478849 Reference #2: PMID: 14665493 Reference #3: PMID: 28275498 DISCLOSURE: The following authors have nothing to disclose: Jie Qu, Elie Berbari No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2017.08.172
Copyright ª 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
chestjournal.org
141A
CHEST INFECTIONS
DISCUSSION: Cryptococcus neoformans is an encapsulated yeast commonly found in soil, pigeon excreta, chickens, and decayed wood. Cryptococcus neoformans commonly infects immunocompromised hosts. We present a rare case of mediastinal cryptococcoma, superinfected with Streptococcus mitis, in an immunocompetent patient. Infection in immunocompetent patients typically manifest as pulmonary nodules, either multiple or solitary, lymphadenopathy, consolidation, or cavitation.