Rapid, Recurrent Unilateral Pleural Effusion Presenting as Cryptococcus Infection in a Non-immunocompromised Host

Cryptococcus neoformans infection presenting as a rapidly reaccumulating unilateral pleural effusion in a non-immunocompromised host is a rare presentation of pulmonary cryptococcal disease. We present a rare case of recurrent unilateral pleural effusion as the initial presentation of cryptococcal disease in an immunocompetent patient. An 85-year-old male with a past medical history of hypertension, hyperlipidemia, diabetes mellitus, chronic kidney disease stage IIIb, and coronary artery disease s/p stent placement in the second obtuse marginal branch of the circumflex artery presented to the emergency department with dyspnea on exertion and an unintentional 30-pound weight loss over two to three months. His prior occupation included work in a tire factory; he denied exposure to asbestos. He chewed tobacco and had a dog. A chest radiograph showed a large right-sided pleural effusion. He had undergone repeated thoracentesis and pigtail chest tube placements over four hospital admissions. Review of the initial cytology, extensive serology, pleural fluid analysis, Gram stain, culture, HIV testing, and adenosine deaminase testing was negative. Given the recurrent hospitalizations and reaccumulation of the right pleural effusion, the decision was made to proceed with endobronchial ultrasound, which demonstrated lymphocytosis without evidence of malignancy. Bronchoalveolar lavage grew 100 colonies of Cryptococcus neoformans. The patient underwent lumbar puncture with an opening pressure of 37 and a negative cryptococcal antigen. He was started on fluconazole 400 mg daily upon discharge, with a suspected treatment course of 12 months and close outpatient pulmonology follow-up. This report highlights a rare initial presentation of Cryptococcus neoformans manifesting as recurrent unilateral pleural effusion.