Images in Clinical Medicine
Pulmonary Cryptococcal Granulomas
N Engl J Med 2002; 347:497August 15, 2002
- Article
Figure 1 A 48-year-old man with diabetes mellitus underwent pancreas–kidney transplantation for end-stage renal disease. One month later, he was treated for rejection, and computed tomography of the chest showed no pulmonary infiltrates. Nine months after transplantation, cryptococcal meningitis developed. He received intravenous amphotericin B–lipid complex, and long-term therapy with oral fluconazole was begun. The serum cryptococcal antigen titer was 1:512 and decreased to undetectable levels over a period of five years. Six years after transplantation, progressive renal-allograft failure developed. A chest radiograph showed multiple nodules confined to the left lung. The patient had no fever and no pulmonary symptoms. Computed tomography of the chest (Panel A) demonstrated 30 variably calcified nodules in the left lung, measuring 1 to 15 mm in diameter. Thoracoscopic lung biopsy showed necrotizing granulomas (Panel B; hematoxylin and eosin, ×13) containing yeast forms (Panel C; methenamine silver stain, ×132). There were both intact and degenerate spores with thick mucin-positive capsules, consistent with the presence of Cryptococcus neoformans (Panel D; mucicarmine stain, ×132). The patient received a second kidney transplant from a living related donor. Nine months after transplantation, serum cryptococcal antigen titers remained undetectable during treatment with 200 mg of fluconazole daily.
Rick M. Fairhurst, M.D.
David A. Pegues, M.D.
UCLA Medical Center, Los Angeles, CA 90095
