Pulmonary cryptococcosis

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Pulmonary cryptococcosis is a form of pulmonary fungal infection caused by Cryptococcus gattii and C.Cryptococcus neoformans. The respiratory tract is the principal route of entry for infection via inhalation of fungal spores.

For a general discussion of infection with this organism, please refer to the article cryptococcosis.

Epidemiology

Cryptococcosis predominantly occurs in immunocompromised patients but can also be seen in immunocompetent hosts, particularly, those exposed to avian (e.g. pigeon) droppings. The spectrum of pulmonary cryptococcosis depends on the host's defenses.

Clinical presentation

The presentation of pulmonary cryptococcosis can range from asymptomatic nodular disease to severe acute respiratory distress syndrome (ARDS) ³:

most often, causes several lung nodules or masses +/- cavitation, chiefly in immunocompromised patients
additionally, consolidation, mediastinal lymphadenopathy, and pleural effusion may also be present.

In the immunocompetent host the pulmonary infections normally are asymptomatic, in contradistinction to the immunocompromised patient, in whom cryptococcal infection is most often symptomatic, and commonly disseminates to the central nervous system, skin, and bones ¹.

Overall, approximately one-third of patients are asymptomatic.

Symptoms range from a mild cough and low-grade fever to acute presentation with high fever and severe shortness of breath.

Pathology

The method of entry is usually by inhalation of cryptococcal particles into the lungs, causing pulmonary infection. Spores are found worldwide in soil contaminated by avian droppings.

Serology

Serum cryptococcal antigen (sCRAG) levels are helpful in diagnosis and follow-up.

Radiographic features

CT

In general, there are several CT patterns that can be seen:

clustered nodular pattern: most prevalent ⁴
solitary pulmonary nodule or mass with or without cavitation
scattered nodules
peribronchovascular consolidation

The most common CT findings in immunocompetent patients with pulmonary cryptococcosis are pulmonary nodules. The nodules are most often multiple, smaller than 10 mm in diameter, and well-defined with smooth margins. The nodules usually involve less than 10% of the parenchyma and tend to be distributed peripherally (up to 65% ¹⁶) in the middle and upper zones. Where there are multiple nodules, they are usually bilateral ². Associated cavitation may be seen in up to 40% of cases ⁸. Occasionally, unusual presentation such as large cavities may be seen ¹³.

Cavitations within nodules/masses tends to be more frequently present in immunocompromised patients than in immunocompetent patients ¹⁶.

Nuclear medicine

FDG PET-CT may play a complementary role to CT ⁶ and ~60% of patients show higher FDG uptake than the mediastinal blood pool ⁴.

Treatment and prognosis

antifungals such as oral fluconazole or intravenous amphotericin B

History and etymology

In 1924,~~Sheppe~~ ~~reported~~ Sheppe reported, for the first time, a case of pulmonary cryptococcosis ¹⁷.

Differential diagnosis

pulmonary tuberculosis
actinomycosis
semi-invasive aspergillosis
other pulmonary fungal infections
primary lung neoplasia
metastatic lung lesion

-<p><strong>Pulmonary cryptococcosis</strong> is a form of <a href="/articles/pulmonary-fungal-disease">pulmonary fungal infection</a> caused by <em>Cryptococcus </em><em>gattii</em> and <em>C.</em> <em>neoformans</em>. The respiratory tract is the principal route of entry for infection via inhalation of fungal spores.</p><p>For a general discussion of infection with this organism, please refer to the article <a href="/articles/cryptococcosis">cryptococcosis</a>.</p><h4>Epidemiology</h4><p><a href="/articles/cryptococcosis">Cryptococcosis</a> predominantly occurs in immunocompromised patients but can also be seen in immunocompetent hosts, particularly, those exposed to avian (e.g. pigeon) droppings. The spectrum of pulmonary cryptococcosis depends on the host's defenses.</p><h4>Clinical presentation</h4><p>The presentation of pulmonary cryptococcosis can range from asymptomatic nodular disease to severe <a href="/articles/acute-respiratory-distress-syndrome-1">acute respiratory distress syndrome</a> (ARDS) <sup>3</sup>:</p><ul>
~~-<li>most often, causes several <a href="/articles/pulmonary-nodule-1">lung nodules</a> or masses +/- cavitation, chiefly in immunocompromised patients</li>~~
+<p><strong>Pulmonary cryptococcosis</strong> is a form of <a href="/articles/pulmonary-fungal-disease">pulmonary fungal infection</a> caused by <em>Cryptococcus </em><em>gattii</em> and <em>Cryptococcus</em> <em>neoformans</em>. The respiratory tract is the principal route of entry for infection via inhalation of fungal spores.</p><p>For a general discussion of infection with this organism, please refer to the article <a href="/articles/cryptococcosis">cryptococcosis</a>.</p><h4>Epidemiology</h4><p><a href="/articles/cryptococcosis">Cryptococcosis</a> predominantly occurs in <a title="Immunocompromised" href="/articles/immunosuppression">immunocompromised</a> patients but can also be seen in immunocompetent hosts, particularly, those exposed to avian (e.g. pigeon) droppings. The spectrum of pulmonary cryptococcosis depends on the host's defenses.</p><h4>Clinical presentation</h4><p>The presentation of pulmonary cryptococcosis can range from asymptomatic nodular disease to severe <a title="Acute respiratory distress syndrome (ARDS)" href="/articles/acute-respiratory-distress-syndrome-1">acute respiratory distress syndrome (ARDS)</a> <sup>3</sup>:</p><ul>
+<li>most often, causes several <a href="/articles/pulmonary-nodule-1">lung nodules</a> or <a title="Pulmonary mass" href="/articles/pulmonary-mass">masses</a> +/- <a title="Pneumonia with cavitation" href="/articles/cavitating-pneumonia">cavitation</a>, chiefly in immunocompromised patients</li>
-</ul><p>The most common CT findings in immunocompetent patients with pulmonary cryptococcosis are <a href="/articles/pulmonary-nodule-1">pulmonary nodules</a>. The nodules are most often multiple, smaller than 10 mm in diameter, and well-defined with smooth margins. The nodules usually involve less than 10% of the parenchyma and tend to be distributed peripherally (up to 65% <sup>16</sup>) in the middle and upper zones. Where there are multiple nodules, they are usually bilateral <sup>2</sup>. Associated cavitation may be seen in up to 40% of cases <sup>8</sup>. Occasionally, unusual presentation such as large cavities may be seen <sup>13</sup>.</p><p>Cavitations within nodules/masses tends to be more frequently present in immunocompromised patients than in immunocompetent patients <sup>16</sup>.</p><h5>Nuclear medicine</h5><p>FDG PET-CT may play a complementary role to CT <sup>6</sup> and ~60% of patients show higher FDG uptake than the mediastinal blood pool <sup>4</sup>.</p><h4>Treatment and prognosis</h4><ul><li>antifungals such as oral fluconazole or intravenous amphotericin B</li></ul><h4>History and etymology</h4><p>In 1924, <strong>Sheppe</strong> reported, for the first time, a case of pulmonary cryptococcosis <sup>17</sup>.</p><h4>Differential diagnosis </h4><ul>
+</ul><p>The most common CT findings in immunocompetent patients with pulmonary cryptococcosis are <a href="/articles/pulmonary-nodule-1">pulmonary nodules</a>. The nodules are most often multiple, smaller than 10 mm in diameter, and well-defined with smooth margins. The nodules usually involve less than 10% of the parenchyma and tend to be distributed peripherally (up to 65% <sup>16</sup>) in the middle and upper zones. Where there are multiple nodules, they are usually bilateral <sup>2</sup>. Associated cavitation may be seen in up to 40% of cases <sup>8</sup>. Occasionally, unusual presentation such as large cavities may be seen <sup>13</sup>.</p><p>Cavitations within nodules/masses tends to be more frequently present in immunocompromised patients than in immunocompetent patients <sup>16</sup>.</p><h5>Nuclear medicine</h5><p>FDG PET-CT may play a complementary role to CT <sup>6</sup> and ~60% of patients show higher FDG uptake than the mediastinal blood pool <sup>4</sup>.</p><h4>Treatment and prognosis</h4><ul><li>antifungals such as oral fluconazole or intravenous amphotericin B</li></ul><h4>History and etymology</h4><p>In 1924, Sheppe reported, for the first time, a case of pulmonary cryptococcosis <sup>17</sup>.</p><h4>Differential diagnosis </h4><ul>

References changed:

1. Nestor Luiz Müller, Tomás Franquet, Kyung Soo Lee (MD.) et al. Imaging of Pulmonary Infections. (2007) ISBN: 9780781772327 - <a href="http://books.google.com/books?vid=ISBN9780781772327">Google Books</a>
2. Lindell R, Hartman T, Nadrous H, Ryu J. Pulmonary Cryptococcosis: CT Findings in Immunocompetent Patients. Radiology. 2005;236(1):326-31. <a href="https://doi.org/10.1148/radiol.2361040460">doi:10.1148/radiol.2361040460</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/15987984">Pubmed</a>
3. Kruglikov R. [Several Neurochemical Mechanisms of Learning and Memory]. Izv Akad Nauk SSSR Biol. 1978;(6):902-10. - <a href="https://www.ncbi.nlm.nih.gov/pubmed/31375">Pubmed</a>
4. Song K, Lee K, Chung M et al. Pulmonary Cryptococcosis: Imaging Findings in 23 Non-AIDS Patients. Korean J Radiol. 2010;11(4):407-16. <a href="https://doi.org/10.3348/kjr.2010.11.4.407">doi:10.3348/kjr.2010.11.4.407</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/20592924">Pubmed</a>
5. Huang C, You D, Lee P et al. Characteristics of Integrated 18F-FDG PET/CT in Pulmonary Cryptococcosis. Acta Radiol. 2009;50(4):374-8. <a href="https://doi.org/10.1080/02841850902756532">doi:10.1080/02841850902756532</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/19242830">Pubmed</a>
6. Hsu C, Lee C, Wang F, Lin Y. F-18 Fluorodeoxyglucose Positron Emission Tomography in Pulmonary Cryptococcoma. Clin Nucl Med. 2003;28(9):791-3. <a href="https://doi.org/10.1097/01.rlu.0000082680.98898.2b">doi:10.1097/01.rlu.0000082680.98898.2b</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/12973014">Pubmed</a>
7. Chang W, Tzao C, Hsu H et al. Pulmonary Cryptococcosis: Comparison of Clinical and Radiographic Characteristics in Immunocompetent and Immunocompromised Patients. Chest. 2006;129(2):333-40. <a href="https://doi.org/10.1378/chest.129.2.333">doi:10.1378/chest.129.2.333</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/16478849">Pubmed</a>
8. Qu Y, Liu G, Ghimire P et al. Primary Pulmonary Cryptococcosis: Evaluation of CT Characteristics in 26 Immunocompetent Chinese Patients. Acta Radiol. 2012;53(6):668-74. <a href="https://doi.org/10.1258/ar.2012.110612">doi:10.1258/ar.2012.110612</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/22798384">Pubmed</a>
8. Fox D & Müller N. Pulmonary Cryptococcosis in Immunocompetent Patients: CT Findings in 12 Patients. AJR Am J Roentgenol. 2005;185(3):622-6. <a href="https://doi.org/10.2214/ajr.185.3.01850622">doi:10.2214/ajr.185.3.01850622</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/16120909">Pubmed</a>
9. Zinck S, Leung A, Frost M, Berry G, Müller N. Pulmonary Cryptococcosis: CT and Pathologic Findings. J Comput Assist Tomogr. 2002;26(3):330-4. <a href="https://doi.org/10.1097/00004728-200205000-00002">doi:10.1097/00004728-200205000-00002</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/12016357">Pubmed</a>
10. Haddad N, Cavallaro M, Lopes M et al. Pulmonary Cryptococcoma: A Rare and Challenging Diagnosis in Immunocompetent Patients. Autops Case Rep. 2015;5(2):35-40. <a href="https://doi.org/10.4322/acr.2015.004">doi:10.4322/acr.2015.004</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/26484332">Pubmed</a>
11. Babu A, Gopalakrishnan R, Sundararajan L. Pulmonary Cryptococcosis: An Unusual Presentation. Lung India. 2013;30(4):347-50. <a href="https://doi.org/10.4103/0970-2113.120618">doi:10.4103/0970-2113.120618</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/24339497">Pubmed</a>
12. Zhang Y, Li N, Zhang Y et al. Clinical Analysis of 76 Patients Pathologically Diagnosed with Pulmonary Cryptococcosis. Eur Respir J. 2012;40(5):1191-200. <a href="https://doi.org/10.1183/09031936.00168011">doi:10.1183/09031936.00168011</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/22408204">Pubmed</a>
13. Morita S, Shirai T, Asada K, Fujii M, Suzuki M, Suda T. Pulmonary Cryptococcosis Presenting with a Large Cavity. Respirol Case Rep. 2014;2(2):61-3. <a href="https://doi.org/10.1002/rcr2.49">doi:10.1002/rcr2.49</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/25473568">Pubmed</a>
14. Lam C, Lam W, Wong Y et al. Pulmonary Cryptococcosis: A Case Report and Review of the Asian-Pacific Experience. Respirology. 2001;6(4):351-5. <a href="https://doi.org/10.1046/j.1440-1843.2001.00345.x">doi:10.1046/j.1440-1843.2001.00345.x</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/11844128">Pubmed</a>
15. Hu Z, Chen J, Wang J et al. Radiological Characteristics of Pulmonary Cryptococcosis in HIV-Infected Patients. PLoS One. 2017;12(3):e0173858. <a href="https://doi.org/10.1371/journal.pone.0173858">doi:10.1371/journal.pone.0173858</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/28301552">Pubmed</a>
16. Xie L, Chen Y, Liu S, Shi Y. Pulmonary Cryptococcosis: Comparison of CT Findings in Immunocompetent and Immunocompromised Patients. Acta Radiol. 2015;56(4):447-53. <a href="https://doi.org/10.1177/0284185114529105">doi:10.1177/0284185114529105</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/24757183">Pubmed</a>
17. Kuykendall S, Ellis F, Weed L, Donoghue F. Pulmonary Cryptococcosis. N Engl J Med. 1957;257(21):1009-16. <a href="https://doi.org/10.1056/nejm195711212572102">doi:10.1056/nejm195711212572102</a>
1. Müller NL, Franquet T, Lee KS et-al. Imaging of pulmonary infections. (2007) ISBN:078177232X. <a href="http://books.google.com/books?vid=ISBN078177232X">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/078177232X?ie=UTF8&tag=radiopaediaor-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=078177232X">Find it at Amazon</a><div class="ref_v2"></div>
2. Lindell RM, Hartman TE, Nadrous HF et-al. Pulmonary cryptococcosis: CT findings in immunocompetent patients. Radiology. 2005;236 (1): 326-31. <a href="http://dx.doi.org/10.1148/radiol.2361040460">doi:10.1148/radiol.2361040460</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/15987984">Pubmed citation</a><div class="ref_v2"></div>
3. Kruglikov RI. [Several neurochemical mechanisms of learning and memory]. Izv Akad Nauk SSSR Biol. (6): 902-10. - <a href="http://www.ncbi.nlm.nih.gov/pubmed/31375">Pubmed citation</a><div class="ref_v2"></div>
4. Song KD, Lee KS, Chung MP et-al. Pulmonary cryptococcosis: imaging findings in 23 non-AIDS patients. Korean J Radiol. 11 (4): 407-16. <a href="http://dx.doi.org/10.3348/kjr.2010.11.4.407">doi:10.3348/kjr.2010.11.4.407</a> - <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2893311">Free text at pubmed</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/20592924">Pubmed citation</a><div class="ref_v2"></div>
5. Huang CJ, You DL, Lee PI et-al. Characteristics of integrated 18F-FDG PET/CT in Pulmonary Cryptococcosis. Acta Radiol. 2009;50 (4): 374-8. <a href="http://dx.doi.org/10.1080/02841850902756532">doi:10.1080/02841850902756532</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/19242830">Pubmed citation</a><div class="ref_v2"></div>
6. Hsu CH, Lee CM, Wang FC et-al. F-18 fluorodeoxyglucose positron emission tomography in pulmonary cryptococcoma. Clin Nucl Med. 2003;28 (9): 791-3. <a href="http://dx.doi.org/10.1097/01.rlu.0000082680.98898.2b">doi:10.1097/01.rlu.0000082680.98898.2b</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/12973014">Pubmed citation</a><div class="ref_v2"></div>
7. Chang WC, Tzao C, Hsu HH et-al. Pulmonary cryptococcosis: comparison of clinical and radiographic characteristics in immunocompetent and immunocompromised patients. Chest. 2006;129 (2): 333-40. <a href="http://dx.doi.org/10.1378/chest.129.2.333">doi:10.1378/chest.129.2.333</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/16478849">Pubmed citation</a><span class="auto"></span>
8. Qu Y, Liu G, Ghimire P et-al. Primary pulmonary cryptococcosis: evaluation of CT characteristics in 26 immunocompetent Chinese patients. Acta Radiol. 2012;53 (6): 668-74. <a href="http://dx.doi.org/10.1258/ar.2012.110612">doi:10.1258/ar.2012.110612</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/22798384">Pubmed citation</a><span class="auto"></span>
8. Fox DL, Müller NL. Pulmonary cryptococcosis in immunocompetent patients: CT findings in 12 patients. AJR Am J Roentgenol. 2005;185 (3): 622-6. <a href="http://dx.doi.org/10.2214/ajr.185.3.01850622">doi:10.2214/ajr.185.3.01850622</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/16120909">Pubmed citation</a><span class="auto"></span>
9. Zinck SE, Leung AN, Frost M et-al. Pulmonary cryptococcosis: CT and pathologic findings. J Comput Assist Tomogr. 2002;26 (3): 330-4. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12016357">Pubmed citation</a><span class="auto"></span>
10. Haddad N, Cavallaro MC, Lopes MP et-al. Pulmonary cryptococcoma: a rare and challenging diagnosis in immunocompetent patients. Autops Case Rep. 2015;5 (2): 35-40. <a href="http://dx.doi.org/10.4322/acr.2015.004">doi:10.4322/acr.2015.004</a> - <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4584666">Free text at pubmed</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/26484332">Pubmed citation</a><span class="auto"></span>
11. Babu AK, Gopalakrishnan R, Sundararajan L. Pulmonary cryptococcosis: An unusual presentation. Lung India. 2013;30 (4): 347-50. <a href="http://dx.doi.org/10.4103/0970-2113.120618">doi:10.4103/0970-2113.120618</a> - <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3841696">Free text at pubmed</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/24339497">Pubmed citation</a><span class="auto"></span>
12. Zhang Y, Li N, Zhang Y et-al. Clinical analysis of 76 patients pathologically diagnosed with pulmonary cryptococcosis. Eur. Respir. J. 2012;40 (5): 1191-200. <a href="http://dx.doi.org/10.1183/09031936.00168011">doi:10.1183/09031936.00168011</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/22408204">Pubmed citation</a><span class="auto"></span>
13. Morita S, Shirai T, Asada K et-al. Pulmonary cryptococcosis presenting with a large cavity. Respirol Case Rep. 2014;2 (2): 61-3. <a href="http://dx.doi.org/10.1002/rcr2.49">doi:10.1002/rcr2.49</a> - <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4184507">Free text at pubmed</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/25473568">Pubmed citation</a><span class="auto"></span>
14. Lam CL, Lam WK, Wong Y, et al. Pulmonary cryptococcosis: a case report and review of the Asian-Pacific experience. (2001) Respirology (Carlton, Vic.). 6 (4): 351-5. <a href="https://www.ncbi.nlm.nih.gov/pubmed/11844128">Pubmed</a> <span class="ref_v4"></span>
15. Hu Z, Chen J, Wang J, et al. Radiological characteristics of pulmonary cryptococcosis in HIV-infected patients. (2017) PloS one. 12 (3): e0173858. <a href="https://doi.org/10.1371/journal.pone.0173858">doi:10.1371/journal.pone.0173858</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/28301552">Pubmed</a> <span class="ref_v4"></span>
16. Xie LX, Chen YS, Liu SY, et al. Pulmonary cryptococcosis: comparison of CT findings in immunocompetent and immunocompromised patients. (2015) Acta radiologica (Stockholm, Sweden : 1987). 56 (4): 447-53. <a href="https://doi.org/10.1177/0284185114529105">doi:10.1177/0284185114529105</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/24757183">Pubmed</a> <span class="ref_v4"></span>
17. Kuykendall, Sam J., Ellis, F. Henry Jr., et al. Pulmonary Cryptococcosis. (2010) <a href="https://doi.org/10.1056/nejm195711212572102">doi:10.1056/nejm195711212572102</a> <span class="ref_v4"></span>

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