Chest
Volume 115, Issue 3, March 1999, Pages 734-740
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Clinical Investigations
Infection
Pulmonary Cryptococcosis in Patients Without HIV Infection

https://doi.org/10.1378/chest.115.3.734Get rights and content

Purpose

To further elucidate the diagnostic and therapeutic approaches to patients with pulmonary cryptococcosis who are not HIV-infected.

Subjects

All of the patients without HIV infection who received care at two Midwest hospitals between January 1986 and February 1996 and had a respiratory isolate of Cryptococcus neoformans.

Methods

The medical records of the study patients were reviewed for demographic data, host immune status, respiratory symptoms, diagnostic studies, treatment, and follow-up.

Results

Forty-two patient presentations comprised the overall study group. Thirty-six patients (85.7%) had no evidence of dissemination, and six patients (14.3%) had disseminated disease. Seven of the 36 patient presentations were definitive pulmonary cryptococcosis, 15 were presumptive disease, and 14 were colonization with C neoformans. Neither the baseline demographic parameters nor the immune status appeared to discriminate the patients with disease from the patients with colonization. A serum cryptococcal antigen (sCRAG) was positive for 7 of 18 patients, 3 of whom were proven by culture to have a disseminated infection. A negative sCRAG was observed in 11 patients, one of whom had proven dissemination. Fifteen patients underwent a lumbar puncture as part of their evaluation, and cryptococcal meningitis was diagnosed in three of these patients, all of whom had positive blood cultures for C neoformans. The majority of the patients did not receive antifungal therapy.

Conclusion

In the majority of the patients, the lung appeared to be the sole organ involved, and a workup for systemic infection was rarely helpful. A positive sCRAG was not specific for dissemination. Antifungal therapy should be reserved for symptomatic patients, for patients with a positive sCRAG, and for patients with underlying immunosuppression.

Section snippets

Patients

All of the patients who received care at Cleveland Clinic Hospital, Cleveland, OH, or at Barnes Hospital, St. Louis, MO, between January 1986 and February 1996 were eligible for study enrollment. The inclusion criteria accepted patients with a growth of C neoformans from a respiratory specimen noted in the clinical mycology laboratory log book of their respective institution. The respiratory specimens were defined as expectorated sputum, induced sputum, BAL, lung biopsy, or lung histopathology

Results

Sixty of 174 patients (34.5%) with isolates of the Cryptococcus spp in their clinical mycology laboratories had respiratory specimens and were eligible for study enrollment. Nineteen patients were excluded, including 11 with a known HIV infection, 5 with a final isolate identified as Cryptococcus albidus, and 3 with unavailable medical records.

Forty-two patient presentations comprised the overall study group. Thirty-six patients (85.7%) had no evidence of dissemination, and 6 patients (14.3%)

Discussion

Cryptococcosis is usually a systemic invasive fungal infection that typically presents as meningitis. In such circumstances, the diagnosis and treatment are relatively straightforward. It is assumed that C neoformans generally gains access to the host by inhalation and that the respiratory system is the usual portal of entry. The evaluation of the significance of respiratory cryptococcal isolates becomes an important part of the decision-making process. Critical decisions in the clinical

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