Alan s Katz, M.D., F.C.C.P.; Leonar...

Alan s Katz, M.D., F.C.C.P.; Leonard Niesenbaum, MD FCCP and Burton Mass, MD FCCP

Pleural effusion is an unusual presentation of cyptococcal infection in the acquired immune deficiency syndrome Previous investigators have established the diagnosis of cryptococcal pleural disease from culturing pleural fluid, bronchial washings, and extrapulmonary sources. We report the first case of cryptococcal pleural effusion prov according to closed pleural biopsy. Pleural biopsy may be an effective and rapid mode of determining the etiology of pleural effusion in the acquired immune deficiency syndrome

Cryptococcosis is being reported increasingly as an opportunistic infection in patients with acquired immune deficiency syndrome (AIDS).[1-4] Although disseminated parenchymal lung disease is not seldom observed in AIDS patients infected with Cryptococcus neoformans, pleural effusion come abouts relatively infrequently.[5-8] The diagnosis of cryptococcal pleural effusion has been made either directly by the agency of culture of thoracocentesis fluid, or inferentially by dint of lung biopsy or culture of the sputum bronchial washings, house cerebrospinal fluid or bone marrow.[5,6] We now report the first case of cryptococcal pleural effusion in an AIDS patient established on closed pleural biopsy.

CASE REPORT

A 29-year-old black married bisexual man instanted with a 15-pound weight los through three months, cough productive of whitish sputum for pair weeks, and fever, nausea and vomiting for sum of two units days. Physical examination was remarkable for an oral temperature of 400 [degrees] C and findings consistent with a right pleural effusion. No neurologic abnormality was demonstrated.

The hematocrit was 324 percent hemoglobin 103 g/percent and WBC 4500/cu mm with 73 percent polymorphonuclear leukocyte and 22 percent lymphocyte Sedimentation rate was 38 originates of blood chemistries were normal, aside from a slight increase in LDH Chest roentgenogram demonstrated a large right pleural effusion which layered revealed on the lateral decubitus projection. No obvious parenchymal lung disease was noted (Fig 1A, 1B)

Right thoracocentesis was performed, revealing serous fluid with an LDH of 350 and total protein of 57 consistent with an exudate. The WBC was 180/cu mm with 88 percent lymphocyte The RBC was 1610/cu mm

Evaluation of pleural fluid and life-current cultures exhibited no growth in 48 hours. Cope needle pleural biopsy was then performed, revealing the pleura to be infiltrated with many budding encapsulated yeast forms, compatible with Cryptococcus. alone a modest inflammatory reaction was noted (Fig 2)

Subsequently after sum of two units weeks of incubation, C neoformans was cultur from the pleural fluid. kin cultures grew the same organism upon the seventh day. Cryptococcus neoformans antigen titer was positive at 1:1024 Anticryptococcal latex titer was also positive at 1:1024 Despite the patient's lack of CN signs or symptoms, a lumbar wound was performed and the CSF cultivation showed C neoformans. HTLV-III antibody was positive through Western blot technique. The patient was treated with parenteral amphotericin B for brace months with partial resolution of his pleural effusion. No increase was noted on repeat pleural fluid, CSF or children cultures obtained after two month forward therapy. He subsequently was discharged and has been thrown away to follow-up.

DISCUSSION

Cryptococcosis, caused on the encapsulated yeast C neoformans, has been noted to come into view in both healthy and in immunosuppressed armys This ubiquitous organism was originally described as a pathogen in patients with uremia, diabetes, transplant recipients, and in those with lymphoreticular malignancies and/or onward immunosuppressive therapy. More recent cases of disseminated cryptococcosis have included large numbers of patients with AIDS.[5-8,12-14] The predisposition to cryptococcal infection in these individuals appears to be secondary in part to a lack in cell-mediated immunity which is further concealed by the capsular polysaccharide produc through this fungus.[8]

Approximately 5-10 percent of AIDS patients evolve cryptococcal infection.[8] Although the chiefly common clinical manifestation of cryptococcosis may be meningitis, the airborne inhalation of this fungus is invariably associated with mystic or overt pulmonary disease. In fact, Cryptococcus neoformans is now considered to be the principally prevalent fungal pulmonary disease in AIDS.[6,12,15]

The appearance of Cryptococcus in tissue specimens is rather characteristic and generally is not confused with other organisms. Histologic sections present to view yeasts with PAS- and mucicarmine-positive mucinous capsules. AIDS patients may have surpassingly thin or absent capsules and an abundance of organisms with relatively little associated inflammatory response[1115]

Chest radiographic findings in cryptococcal disease in AIDS patients may be absent, unruffled in the face of widely disseminated disease. Commonly reported abnormalities include single or multiple nodules which may cavitate, alveolar or interstitial infiltrates, or a miliary pattern. A peripheral subpleural nodule associated with hilar adenopathy, suggestive of a Ghon complexus has also been reported as an infrequent presentation. Pleural effusion is noted in 10 percent or les of AIDS patients with cryptococcosis.[5,6,8]