Pulmonary Cryptococcosis.

INTRODUCTION A 15-year-old previously healthy female presented to the emergency room after 2 months of shortness of breath due to presumed bronchitis and new seizure activity. The patient had previously been treated with 2 courses of antibiotics, prednisone, albuterol, and montelukast. Upon admission the patient underwent a brain MRI that was normal. The patient was subsequently discharged but returned 1 week later for repeat MR of the brain which was again normal; however abnormal signal at the right lung apex suspicious was noted on the MRA (Figure 1). A subsequent first chest radiograph demonstrated a large mass within the right upper lobe with a crescentic lucency along its superior aspect and mass effect on the right mainstem bronchus and the bronchus intermedius (Figure 2). CT of the chest demonstrated a large, heterogeneous, well-circumscribed 11 cm cavitary mass in the right upper lobe with irregular areas of crescentic air along the perimeter of the cavity (Figure 4). There was mass effect on the right pulmonary artery without evidence of vascular invasion. There was also compressive atelectasis in the adjacent right middle lobe. The patient subsequently underwent bronchoscopy and biopsy that showed Cryptococcus neoformans. The patient subsequently developed increasing headaches and a ring-enhancing lesion was identified adjacent to the right caudate on a repeat brain MRI (Figure 3). Lumbar puncture showed elevated opening pressure and cerebrospinal fluid (CSF) cultures were positive for Cryptococcus. The patient was started on flucytosine for treatment of cryptococcal meningitis. A few weeks later the patient underwent resection of the right upper lobe cavitary