| [Objective] Describe the clinical menifestations, imaging findings, titers of serum Cryptococcus antigen (sCRAG), pathological findings, treatment and prognosis of.pulmonary cryptococcosis in patients with different immunological status, in order to improve the clinical diagnosis and treatment of pulmonary cryptococcosis.[Methods] The medical records of 100 patients diagnosed with pulmonary cryptococcosis at major Hospitals in Shanghai including Zhongshan Hospital between Jan.1998 and Dec.2009 were reviewed retrospectively, including general conditions, clinical menifestations, imaging findings, laboratory results, sCRAG titers, pathological findings, complications, treatment and prognosis. Compare the differences in patients with different immunological status. Statistical analysis was conducted using SPSS for Windows (version 17.0). The continuous data were expressed as means±standard deviation for those with a normal distribution. Discrete data were expressed as percentages. Student's unpaired t-test was used to compare continuous variables, and the Pearson Chi-squared or Fisher's exact test was used to compare proportions. [Results]1) The mean(±SD) age of the 100 patients was 45.40±12.19 (range,18-75), and 74.00% of whom were in the age between 31 and 60. The ratio of the male and female patients was 1.54:1. The mean(±SD) age of the non-immunocompromised patients was 45.68±12.19(range,18-75), and male/female ratio was 1.39:1. The mean(±SD) age of the immunocompromised patients was 44.62±12.65(range,22-64), and male/female ratio was 2.25:1. There were no significant deviations of age and sex between two groups.2) 46.00% (46/100) of the patients with pulmonary cryptococcosis have no history of diseases. The rest have one or more diseases.3) The patients mainly complained of symptoms as follows:cough (61.00%), expectoration (41.00%), fever (34.00%), chest pain (17.00%).23 patients (23.00%) were asymptomatic, who had abnormal chest radiographs during a routine physical examination. Most of the non-immunocompromised patients were asymptomatic or complained of cough and expectorations. Most of the immunocompromised patients complained of fever, cough and exectoration. There was a significant deviation of clinical menifestations between two groups. (P<0.05)4) The lesions of 59 cases were under the plierapulmonalis, and it mainly involved unilateral lung with the rate of 67.00%.52.00% of the lesions involved single lung lobe. The lesions of 66.22% non-immunocompromised patients were under the pleurapulmonalis. The lesions of 61.54% immunocompromised patients distribute randomly. There was a significant deviation between two groups (P< 0.05). The lesions of 72.97% non-immunocompromised patients involved unilateral lung. The lesions of 50.00% immunocompromised patients involved unilateral lung. There was a significant deviation between two groups (P< 0.05). The lesions of 59.46% non-immunocompromised patients involved single lung lobe. The lesions of 69.23% immunocompromised patients involved multiple lung lobes. There was a significant deviation between two groups (P< 0.05). The radiologic findings of 49.00% (49/100) patients were nodules and masses.22.00% (22/100) were patchy infiltrates.23.00 % (23/100) were mixed patterns.60.00% (60/100) were complicated with cavity, mediastinal lymph nodes or air bronchogram. The most common radiologic finding of non-immunocompromised patients was nodules or masses(55.41%). The next is mixed patterns(22.97%). The remaining presented infiltrates(21.61%). The radiologic findings of immunocompromised patients were variable, including patchy infiltrates(23.08%), mixed patterns(23.08%), nodules or masses(30.77%), diffuse granular shadows(15.38%), interstitial fibrosis(7.69%). There was a significant deviation between two groups (P< 0.05)5) The leukocyte count of 5.41% non-immunocompromised patients was high, and that of 23.08% immunocompromised patients was high. The neutrophilic granulocyte percentage of 10.81% non-immunocompromised patients was high, and that of 30.77% immunocompromised patients was high. The C-reactive protein of 16.22% non-immunocompromised patients was high, and that of 46.15% immunocompromised patients was high. There were significant deviations of the leukocyte counts, neutrophilic granulocyte percentage and C-reactive protein between two groups (P <0.05).6) 64 cases had the sputum culture for Cryptococcus Neuformans, with the positive rate of 4.69%.6 case had the bronchoalveolar lavage fluid culture for Cryptococcus Neuformans, with the positive rate of 33.33%.1 case had the suction flow culture, with the positive rate of 100%.9 cases took the transbronchial lung biopsy tissue culture, with the positive rate of 22.22%.14 cases took the percutancous cutting needle biopsy tissue culture, with the positive rate of 21.43%.8 cases had the blood culture for Cryptococcus Neuformans, with the positive rate of 50.00%.24 cases had the cerebrospinal fluid smear and culture for Cryptococcus Neuformans, with the positive rate of 29.17%. The CSF smear and culture of 6.25% non-immunocompromised patients were positive, and that of 75.00% immunocompromised patients were positive. There was a significant deviation between two groups(P<0.05).7) 83 cases had the latex agglutination test for Cryptococcus, including 64 non-immunocompromised patients(57 positive) and 19 immunocompromised patients(all positive). The immunocompromised patients generally had a high titer,88.24% of which had a titer of more than 1:640. Only 50.00% of the non-immunocompromised patients had a titer of more than 1:640. There was a significant deviation between two groups (P< 0.05). The latex agglutination test of 80.77% patients with single lesion was positive, and that of 96.49% patients with multiple lesions was positive. There was a significant deviation between two groups (P< 0.05). The latex agglutination test of 80.56% patients with nodules or masses was positive, and that of 96.49% patients with other lesion type was positive. There was a significant deviation between two groups (P< 0.05).8) 14 cases were diagnosed by the histological specimens of the transbronchial lung biopsy.26 cases were diagnosed by the histological specimens of the percutancous cutting needle biopsy.21 cases were diagnosed by the histological specimens of operation. The most common pathology phenotype was inflammatory granuloma; with a rate of 86.21%. Nodular fiber-like granuloma was less to see. Only one was mucoid gum-like lesion. There was no significant deviation of pathology phenotype between non-immunocompromised and immunocompromised patients.9) 52.00% of the patients were misdiagnosed, including lung cancer(19.00%), tuberculosis(8.00%), pneumonia(22.00%), sarcoidosis(2 .00%),organizing pneumonia(1.00%).10)One non-immunocompromised patient (1.35%) was complicated with cryptococcal meningitis, and 6 immunocompromised patients (23.08%) were complicated with cryptococcal meningitis., There was a significant deviation of complication . between two groups (P<0.05)11) 77.00% of the patients were treated with medicine,3.0.0% with operation, 18.00% with operation combined with medicine,2.00% untreated.82.14% of the patients were improved or cured. The rate of death was 4.76%, and that of recurrence was 3.57%.89.06% of the non-immunocompromised patients were improved or cured and the rate of death was.0.0%. Only 60.00% of the immunocompromised patients were improved or cured, and the rate of death was 20.00%. There was a significant deviation of prognosis between two groups(P< 0.01).8 cases were treated with itraconazole, and all of them were cured or improved.[Conclusion]1) Pulmonary cryptococcosis mainly involves the middle ages. It is more offen to see in the males than the females2) Many patients with pulmonary cryptococcosis have no history of diseases. Patients without history of diseases cannot be excluded from pulmonary cryptococcosis.3) Pulmonary cryptococcosis with no symptom is more to see in non-immunocompromised hosts, and the immunocompromised patients often show the symptoms of fever, cough and expectoration.4) The most common imaging findings of pulmonary cryptococcosis are nodules, masses or patchy infiltrates.60% patients have the images of cavity, mediastinal lymph nodes or air bronchogram.5) The lesions of non-immunocompromised patients are mainly under the plierapulmonalis, involve unilateral lung and limit to a single lobe. Most of them are nodules and masses. 6) The imaging findings of immunocompromised patients are variable. The lesions distribute widely and randomly. Diffuse granular shadows and interstitial fibrosis are more to see in immunocompromised patients.7) The latex agglutination test for Cryptococcus contributes to the diagnosis of pulmonary cryptococcosis.The sensitivity of the test is higher in multiple lesions than in single lesion, and it has a greater value of diagnosis.8) The high sCRAG titer (≥1:640) is more to see in immunocompromised patients than in non-immunocompromised patients.9) Pulmonary cryptococcosis complicated with cryptococcal meningitis is more to see in immunocompromised patients than in non-immunocompromised patients, and it has a higher rate of death. Cryptococcal meningitis should be ruled out in immunocompromised patients.10)The immunocompromised patients have a higher rate of positive in the blood culture for Cryptococcus Neuformans. The blood culture for Cryptococcus Neuformans maybe has an important value of diagnosis. The patients with blood culture positive have.a worse prognosis.11)TBLB and PCNB have a high rate of positive in the diagnosis of pulmonary cryptococcosis, and they can complete each other.12) It should be noticed that itraconazole can be used as an alternative treatment for fluconazole. |
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