Pulmonary cryptococcosis in an HIV-negative population

Background: Few studies have been published examining the CXR patterns, presenting features and diagnosis of pulmonary cryptococcosis in HIV negative populations, leading to a paucity of reported experience on which to base therapeutic guidelines. Method: A review of the medical records and chest X-rays of 52 consecutive HIV negative patients from 1979 onwards with proven cryptococcosis (due to Cryptococcus neoformans neoformans) was undertaken at The Prince Charles Hospital - a tertiary referral centre for cardiothoracic disorders. Results: The median age of patients presenting with pulmonary cryptococcosis was 42 years; 67% were male and 94% Caucasian. The commonest presenting symptoms were: cough (51%), pleuritic pain (45%), fever (23.5%). Eight patients presented with concurrent meningeal involvement. Possible predisposing conditions to pulmonary cryptococcosis included sarcoidosis (2), dialysis (1), rheumatoid arthritis (1), S.L.E. (1), orthotopic heart transplantation (1), post-partum (3), NIDDM (1). Seven patients were on immunosuppressive medication. The CXR was positive in all 52 patients, the most frequently occurring radiographie pattern being that of pulmonary masses, followed by air space consolidation. There was no statistically significant difference among lobar distributions. Serum cryptococcal antigen was positive in 74% cases and in the CSF in only 17% of patients (all with meningitis). Of 45 patients treated with drug therapy, 60% received amphotericin and flucytosine; 22% fluconazole. Eighteen patients underwent surgery. Four cases were left untreated. Residual disability was detected in only 6 patients, all of whom presented with concurrent meningitis. Conclusion: In this series of patients, a combination of modalities was required to make the diagnosis. Radiographie abnormalities tended to differ from those reported in HIV positive patients.Treatment was undertaken in patients using amphotericin, flucytosine or fluconazole.Surgery was reserved for nonresponsive disease or in diagnostic uncertainty. Of patients not treated, disease burden was perceived as minimal or resolving and was monitored by close follow-up.