Case Presentation:
A 53‐year‐old male with HIV presented with a two‐week history of dry cough, fever, and shortness of breath. His past medical history included disseminated Cryptococcus neoformans treated with fluconazole, a 20‐pack‐year smoking history, and a remote history of thoracotomy following a stab wound to the chest. He had recently started highly active antiretroviral therapy (HAART), with an increase in his CD4 T‐cell count from 12 to 51 cells/μl. A large left‐sided pleural effusion was seen on chest radiograph. The patient underwent thoracentesis, revealing an exudative effusion with normal cytology and negative fungal and bacterial cultures. An ill‐defined mass in the left lower lobe of the lung was discovered on a routine chest radiograph following the procedure. A computerized tomography (CT) scan of the chest was then obtained and showed a 3 × 5 cm heterogeneous mass with central necrosis and several smaller nodules in the chest bilaterally. Given the patient's tobacco use, there was concern these findings represented a primary lung malignancy with metastases. A periaortic lymph node was biopsied using CT‐guidance, and the histology showed extensive granulomatous inflammation and C. neoformans organisms by Gomori methenamine silver (GMS) stain. No evidence of malignancy was found. Treatment with fluconazole was continued with plans to start steroid therapy if the pleural effusion reoccurred.
Discussion:
The lung cryptococcoma and pleural effusion seen in this patient are unusual manifestations of C. neoformans. Rather than inadequate treatment of his underlying infection, inflammation and granuloma formation in the setting of Immune Reconstitution Inflammatory Syndrome (IRIS) accounted for the severity of this patient's presentation. IRIS occurs in up to 25% of patients who start HAART, and its clinical presentation depends on both the type and location of the previous opportunistic infection. Features of IRIS in this patient include his low initial CD4 count, his rapid response to HAART, the onset of his symptoms shortly after starting HAART, and the negative cultures of his pleural fluid. A review of the medical literature from 1966 to 2005 using OVID and PubMed found no reports of pulmonary cryptococcomas in the setting of IRIS. However, there are descriptions of patients with adequately treated central nervous system (CNS) cryptococcosis who developed severe aseptic meningitis and, rarely, CNS cryptococcomas after starting HAART.
Conclusion:
Although antiretroviral therapy is lifesaving, physicians must be aware of its potential complications. Lung masses and effusions have a broad differential in the setting of HIV, and the diagnosis of cryptococcoma was a favorable alternative to malignancy for this patient.
Author Disclosure Block:
J. Robinson, None; D. Dressler, None.