Patient Data

� Name : 胡XX

� Gender : male

� Age : 35 years old

Chief Complaint

� Cough with purulent sputum for 2~3 months

Present Illness

� Cough with yellowish sputum for 2-3 months � Dyspnea(-) , hemoptysis(-), chest pain(-), DOE(-) ,

orthopnea(-), fever(-), weight loss(-) � Visit to ENT OPD first on 8/24 where CXR showed

RLL nodule� Clarithromycin was given ,and the yellowish sputum

was improved. � Right lower lung nodule still noted on following CXR

on 9/1 and 9/8. � Chest CT was done and showed a 2x1 cm lung

nodule over right lower lung

Past History

� Medical:

Denied

� Surgical:

Denied

� Allergy:

Denied

Travel History

� History of oversea travel in recent 3 months: not found.

� History of contact with animals or sick people: negative

Personal History

� Smoking：smoking for 20 years (1 PPD)

� Alcohol use：denied

� Drug abuse：denied

� Betel nut chewing：denied

Family History

� No malignancy famil history

Lab Data

Chest x-ray on 8/24

� An ill-defined nodular shadow in right lower lung field

Following CXR on 9/1 and 9/8

CT C- on 9/15� An irregular mass with spiculations at the

right lower lobe measuring about 1.7 cm in diameter

� No sign of mediastinal lymphadenopathy. � The mediastinum is centered and of

normal width. There is no evidence of masses in the anterior, middle and posterior compartment.

� The hilar region on each side is unremarkable, and the main bronchi appear normal.

� Impression：Right lower lobe lung CA.

Tumor size: 1.7 cm Tumor location and invasion: RLL with spiculation. Lymphadenopathy: none Distant metastasis: unknown Image stage (TNM): T1a N0 Mx

CT-guided Biopsy on 9/16

Single Pulmonary Nodule—D/D

Bronchogenic carcinoma

� Poorly-defined

� Hilar and mediastinal enlargement common,particularly in small cell carcinoma

� Cavitation with thick wall (esp in SCC)andpleural effusion in 10% each.

� Calcification very rare(ruled out if central calcification, popcorn are seen)

A lobulated and spiculated nodule in lower lobe. Comfirmed as a

NSCLC.

A spiculated nodule with eccentric cavitation in upper

lobe. Pathology comfirmed a NSCLC.

A lobulated, sharply

marginated nodule in the

upper lobe.

CT reveals amorphous

calcification in the nodule, a

pattern that is typical of

malignancy. Adenocarcinoma was

confirmed at resection.

Metastasis

� Solitary or multiple(hematogeneous in 75%)

� Usually well-circumscribed lesions

� Cavitation occur in 4%

� Calcification usually in metastasis from bone tumor or GI neoplasm

A smoothly marginated, 1cm peripheral nodule. Metastatic

disease was confirmed by resection.

Metastatic osteosarcoma.

CT showed a small, high

attenuation nodule in lower

lobe. Suggestive of a benign

lesion.

8 months later, CT revealed a

interval growth of the nodule,

which has high attenuation with

lobulated contour.

Hamartoma

� Solitary, well-circumscribed, often lobulated

� In peripheral lung

� Up to 4 cm

� Calcification occurs, diagnostic when resembling popcorn

� Fat density

� Peak incidence in 6th decade

Abscess

� Solitary or multiple round lesions

� 1cm~several cm

� Poor defined in acute stage, good defined in chronic stage

� Predilection for lower lobe and posterior segment of upper lobe

� Cavitation is very common with thin wall

Discussion-Cryptococoosis

�A chronic, subacute to acute pulmonary, systemic or meningitic disease, initiated by the inhalation of the fungus.� Primary pulmonary infections have no diagnostic symptoms and are usually subclinical. � On dissemination, the fungus usually shows a predilection for the central nervous system, however skin, bones and other visceral organs may also become involved.

�Aetiological Agent: Cryptococcus neoformans.

Cryptococcosis

Cryptococcus - epidemiology

� Increasing proportions of patients have an underlying immune deficiency –� HIV/AIDS

� Accounts for up to 50% cryptococcal infections

� CD 4 < 200

� Incidence has declined in Australia since advent HAART

� Prolonged steroid therapy

� Organ transplantation

� Malignancy

� Sarcoidosis

Clinical Manifestations

� Pulmonary cryptococcosis� Asymptomatic carriage may occur in healthy people as

well as those with chronic lung disease

� May experience a self limited pneumonia

� Invasive chronic pulmonary disease may occur and may disseminate to the CNS

� CNS disease� Meningitis (85%), meningoencephalitis, cryptococcoma

� Generally symptoms more insidious and of longer duration in the non-immunosuppressed

� Higher burden of organisms in AIDS, with variable inflammatory response, which parallels degree of immunosuppression

Clinical manifestations

� Cutaneous cryptococcosis� Ulcerated or nodular lesions – usually portend poor

prognosis in disseminated disease

� cellulitis

� Bone and joint disease� Lytic lesions in up to 10% with disseminated disease

� Ocular cryptococcosis� Rare, other than pressure effects

� Genitourinary disease� Prostate acts as sanctuary site in immunosuppressed

Diagnosis� High index of suspicion needed

� Lumbar pucture� Measure + record opening pressure

� Repeat at least fortnightly during therapy and daily if pressure > 25 cmH2O

� India ink examination

� CSF WCC (usually mononuclears) typically low (< 50) in those with advanced immunosuppression

� CSF glucose + protein often only minimally abnormal

� Cryptococcal antigen assay

� Rapid diagnostic test

� Rare false positives

� Titre generally correlates to organism burden

� Serum assay useful screen in AIDS patients

Diagnosis

� Extraneural cultures

� Occasionally positive from another site

� Full evaluation needed to exclude disseminated disease, or CNS disease

� Radiology

� Detection of cryptococcomas

� May detect hydrocephalus -> need for shunt

Chest Radiological Features

� Size:variate from barely visible to huge

� Usually single but may multiple

� No predilection for any lobe or zone

� Funfus+ inflammatory response� well-defined mass

� Fibrous tissue + central caseation � poorly defined lesion,cavitation(+/-)

� Difficult to distinct from bronchial carcinoma �biopsy,bronchial washing,sputum culture

Treatment

� CNS disease uniformly fatal without Rx

� Immunocompromised patients need long term suppressive therapy, unless immune status substantially recovers

� Aim for complete eradication of organism in the nonimmunosuppressed:� Amphotericin B 0.5-0.7 mg/kg/d + flucytosine

100-150 mg/kg/d for 6 weeks followed by fluconazole 400 mg/d for 3-6 months+

� Debate re switch to fluconazole after 2 weeks if favourable clinical(including LP) response

Treatment

� In HIV/AIDS most switch early to oral therapy, or use high dose oral fluconazole from the outset if mild disease

� Liposomal amphotericin if develop toxicity

� ? New azoles

� Echinocandins have no anticryptococcal activity

� Management of raised intracranial pressure often the most problematic issue� Large volume (30-50 mL) CSF removal up to daily

� Shunt or drain placement (does not prevent clearance of infection)

� Steroids generally of no use in management of pressure, except where oedema associated with cryptococcomas