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Cryptococcal pleural infection in a recurrent pleural effusion: a case report
Audrey Chuan Rui Wee1, Ju Ee Seet2, Jonathen Venkatalacham1
1Department of Respiratory and Critical Care Medicine Khoo Teck Puat Hospital Singapore.
Abstract:
Cryptococcal pleural infection is rare with about 50 cases reported. It tends to occur in immunocompromised individuals. We describe a 38-year-old male who presented with a lymphocytic exudative right pleural effusion and a raised pleural fluid adenosine deaminase (ADA) level. He was initially treated for pleural tuberculosis, but presented again with worsening pleural effusion 6 weeks later. A thoracoscopic pleural biopsy revealed chronic nodular granulomatous pleuritis with cryptococcal organisms present. The repeat pleural fluid culture was positive for Cryptococcus neoformans. He was started on intravenous amphotericin B and oral flucytosine for 1 week, and then continued on oral fluconazole. He was subsequently diagnosed to have acute myeloid leukaemia. His peripheral blood film showed presence of blast cells (33%), with flow cytometry showing increased myeloblast population. Lymphocytic exudative pleural effusions with raised ADA levels in an immunocompromised patient can be due to opportunistic fungal infections.
Insights
Cryptococcal pleural infection, a rare fungal disease, can mimic tuberculosis in immunocompromised patients. Early diagnosis and treatment are crucial for managing this opportunistic infection, especially in individuals with hematologic malignancies.
Area of Science:
- Infectious Diseases
- Pulmonology
- Oncology
Background:
- Cryptococcal pleural infection is a rare clinical entity, with limited reported cases.
- The condition predominantly affects immunocompromised individuals, presenting diagnostic challenges.
- Pleural effusions in immunocompromised patients can be caused by various pathogens, including fungi.
Observation:
- A 38-year-old male presented with lymphocytic exudative pleural effusion and elevated adenosine deaminase (ADA) levels.
- Initial treatment for presumed pleural tuberculosis was unsuccessful, with disease progression.
- Thoracoscopic pleural biopsy revealed granulomatous pleuritis with Cryptococcus organisms.
Findings:
- Pleural fluid culture confirmed *Cryptococcus neoformans* infection.
- The patient was diagnosed with acute myeloid leukemia (AML) with significant blast cell presence.
- This case highlights opportunistic fungal infections presenting as exudative pleural effusions with elevated ADA.
Implications:
- Raised pleural fluid ADA levels and lymphocytic exudative effusions in immunocompromised patients warrant consideration of opportunistic fungal infections.
- Prompt identification and treatment of cryptococcal infections are vital in immunocompromised hosts, particularly those with hematologic malignancies.
- This case underscores the importance of a broad differential diagnosis in immunocompromised patients with pleural effusions.
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