Clinical Features And Surgical Treatment Of Patients With Primary Pulmonary Cryptococcosis Presenting With Lung Nodular Or Mass

ObjectivePulmonary cryptococcosis is most common in immunocompromised patients and immune-competent hosts are rarely affected.With the use of broad-spectrum antibiotics,glucocorticoids,immunosuppressive agents,cytotoxic drugs and the number of organ transplantation and AIDS patients increasing,the incidence of pulmonary cryptococcosis is gradually rising in immunocompetent groups.Pulmonary cryptococcosis is difficult to identifying by most clinicians and atypical clinical manifestations lead to delayed diagnosis or even misdiagnosis.Aiming to improve clinicians' understanding of pulmonary cryptococcosis and provide a reference for clinical diagnosis and treatment,this study mainly discussed the clinical features and surgical treatment of primary pulmonary nodular pulmonary cryptococcosis.MethodFourteen patients undergon surgery and pathologically diagnosed as pulmonary cryptococcosis in the Department of Thoracic Surgery,Qilu Hospital of Shandong University from January 2008 to August 2017 were enrolled in this study.ResultThis study included 14 patients with a mean age of 56.6 years old(range from 42 years old to 71 years old),among which 7(50.0%)were male and 7(50.0%)were female.Five(35.7%)cases had underlying diseases and all patients did not undergo organ transplantation,and HIV test was negative.Two patients(14.3%)had a history of directly contacting with pigeon feces,4 patients(28.6%)were infected with fungal spores in the working or living environment and 42.9%(6 cases)of patients with pulmonary cryptococcosis had a direct or indirect potential for environmental exposure history.Eight patients(57.1%)had no symptoms and signs of pulmonary infection and were found by accidental examination.The most common symptoms were cough,sputum and chest pain.All patients underwent CT examination.Lesions were found in all lobes and all were located on one side of the lung with a ratio of 1.8:1 in the right and left lungs.There were 13(92.9%)cases in type of nodule and 1 case in type of mass and 11 cases(78.6%)located in the peripheral zone of the lung.Thirteen cases(92.9%)were solitary lesions and 1 case(7.1%)was multiple nodules.Lobulated lesion was seen in 7 cases(50.0%)speculation was seen in 10 cases(71 4%),pleural traction was seen in 3 cases(21.4%),vacuolar sign was seen in 3 cases(21.4%),empty sign was seen in 3 cases(21.4%)and enlarged hilar or mediastinal lymph nodes were seen in 2 cases.All cases were misdiagnosed as lung cancer,pneumonia or tuberculosis,among which 7 cases had focal enhancement.None cases had consolidation of the lung and pleural effusion.Two patients underwent 18F-FDG PET/CT with uptake standardized uptake values(SUVs)greater than 2.5,and the report could not rule out malignant lesions.Five patients were treated with anti-inflammatory preoperatively and one patient was treated with anti-tuberculosis drugs,all of which were ineffective.In this study,all patients underwent surgical treatment and the lesions were completely resected in all cases,among which 11 patients(78.6%)underwent partial resection of the lesion and 3(21.4%)underwent lobectomy.The lung tissues were sent to be tested through rapid pathology intraoperatively in cases of partial resection.The pathological reports were granulomatous inflammation.Multinucleated giant cells with cryptococcosis in or out of them were seen in postoperative routine pathological examination,and all the lung tissue sections were positive after PAS staining.Three patients underwent mediastinal lymph nodes resection during operation,and all of the lymph nodes showed reactive hyperplasia in routine pathology,among which 1 case was found lymphogranulomatous inflammation.Ten patients(71.4%)received surgical treatment only,and 4(28.6%)patients continued antifungal therapy after surgery,two of whom received fluconazole(200 mg bid)and the other two took itraconazole(200 mg bid).During 6 months to 86 months follow-up,all of the 14 patients recovered and no recurrence tendency.ConclusionThe incidence of pulmonary cryptococcosis in normal immune population gradually increased,and is closely related to the environmental exposure history.The clinical symptoms of pulmonary cryptococcosis,laboratory tests and images lack specificity,which lead to easily misdiagnosis as lung cancer,Pneumonia and tuberculosis,especially for isolated nodular tumor of pulmonary cryptococcosis.The lung puncture or bronchoscopy is the proposed method for patients with high suspicion of this disease.Medical antifungal therapy is feasible treatment for patients who had been diagnosed as pulmonary cryptococcosis by histopathology,while surgery is the proposed treatment for patients who cannot be diagnosed as pulmonary cryptococcosis and are difficult to being differentiated from lung cancer,because the incidence of lung cancer is higher than cryptococcosis and cancer is a fatal disease.Patients with primary nodular mass pulmonary cryptococcosis can be cured by surgery alone and the preferred surgical approach is local resection.Patients with complete resection of the lesion may not need antifungal treatment after surgery,but they must be closely observed and regularly reviewed.