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