Pulmonary cryptococcosis - lung transplant

Case contributed by Dr Bruno Di Muzio

Presentation

Previous history of bilateral lung transplant.

Patient Data

Age: 35 years
Gender: Male
X-ray

Chest radiographs

There is a relatively well-defined RUL pulmonary nodule. The lungs and pleural spaces are otherwise clear. Right-sided port-a-cath in situ. 

CT

CT Chest

There is a 15 mm right upper lobe lobulated nodule, no other relevant lung abnormalities. Pleural spaces and airways are normal. No mediastinal lymphadenopathy. 

The patient went for a wedge resection: 

Macroscopy: Labelled "Right upper lobe wedge". Wedge weighing 6.5 g (post-inflation) measuring 60 x 18 mm. Pleura appears pale tan/grey. Centrally there is a pale tan/cream cavitating lesion measuring 16 x 13 x 11 mm. This is less than 1 mm from the green inked stapled resection margin and has opened to the pleural surface. Background parenchyma appears pale tan. 

Microscopy: The sections show lung tissue with overlying visceral pleura. The parenchyma contains a cavitating lesion filled with fibrin and necrotic debris, with a periphery showing a histiocytic and granulomatous inflammatory reaction with localised fibrosis. Within the necrotic zone, there is frequent round yeast with distinct walls, surrounded by clear retraction spaces. The features are of a Cryptococcal abscess. Away from the lesion, the alveolar tissue has a normal architecture. There is no evidence of malignancy.

Conclusion:  Right upper lobe lung, wedge excision: Features of an acute on chronic Cryptococcal abscess. 

 

Case Discussion

This case shows an immunocompromised patient post bilateral lung transplant with no respiratory symptoms and presenting with a right upper lobe solitary pulmonary nodule. The new relatively well-defined lesion was highly concerning for a fungal infection. PTLD and other differentials were felt less-likely. 

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Case information

rID: 61829
Published: 29th Jul 2018
Last edited: 30th Jul 2018
System: Chest
Inclusion in quiz mode: Included

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