Pulmonary Disease

	Answer 3 Lumbar puncture. The lungs are thought to be the primary portal of almost all cryptococcal infections. Infection disseminates through the blood, frequently causing meningoencephalitis. Meningitis is the most common initial manifestation of cryptococcal infection in both HIV-infected and non-HIV- infected patients.4 Pulmonary cryptococcal infection is the second most common presentation of cryptococcal infection and the cause of this patient’s symptoms. Symptoms, which may be present from a few days to a few weeks, are nonspecific and commonly include cough, fever, dyspnea, thoracic pain, and headache. On computed tomography, solitary or multiple subpleural pulmonary nodules are the most common finding. Patients may also have air-space consolidation, interstitial micronodules or reticulomicronodules, or lymphadenopathy. Diagnosis of cryptococcosis requires direct evidence in sputum, bronchial washings, bronchoalveolar lavage fluid, or biopsy. Indirect proof in the form of cryptococcal antigen in the blood or cerebrospinal fluid may also be useful. Because most immunocompromised hosts will present with extrapulmonary disease, all patients with a positive respiratory sample should be evaluated for disseminated disease, even in the absence of symptoms. It is important to rule out central nervous system involvement to determine if intracerebral pressures should be decreased with serial lumbar punctures and to establish the need for flucytosine therapy for synergy. In this case, because there is direct evidence of pulmonary cryptococcosis (biopsy specimen), sputum analysis and transthoracic needle biopsy are not necessary. Testing for anticryptococcal antibodies is not useful for diagnosis or management of cryptococcal infection because it can be negative in many cases. Results of antigen titers would not guide management of infection caused by Cryptococcus. Typing of clinical isolates is typically only used for research purposes. REFERENCE 4. Lortholary O, Nunez H, Brauner MW, Dromer F. Pulmonary cryptococcosis. Semin Respir Crit Care Med 2004;25:145–57. Click here to return to the questions
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