Cryptococcus gattii: an emerging fungal pathogen in the southeastern United States

The authors present a case of severe meningoencephalitis with cryptococcomas and hydrocephalus due to Cryptococcus gattii of the molecular type VGI in an otherwise healthy man native to Southwest Georgia without any history of travel. Clinicians need to be aware of this fungal emerging pathogen in the Southern United States.     

Primary pulmonary haemangiopericytoma: a very rare case

Hemangiopericytoma is a mesenchymal neoplasm originating from pericytes--a cell type that surround capillaries. Its primary localization in the lung is extremely rare. A 41-year-old male patient was admitted to our hospital with an abnormal opacity on his chest X-ray. A primary tumor, located in the left upper lobe, was resected, and final diagnosis was hemangiopericytoma of pulmonary origin. The patient has been well for 2 years since the operation with no sign of recurrence or metastasis. A rare case of primary pulmonary tumor has been presented, and possibilities and difficulties in diagnosis as well as therapy are discussed.     

Indeterminate pulmonary nodules in colorectal cancer

AIM:To investigate the clinicopathologic parameters of pulmonary metastasis in colorectal cancer(CRC) patients after lung operation of indeterminate pulmonary nodules(IPNs).METHODS:From a prospective database of CRCpatients,40 cases that underwent lung operation between November 2008 and December 2012 for suspicious metastatic pulmonary nodules on chest computed tomography(CT)were enrolled.The decision to perform a lung operation was made if the patient met the following criteria:(1)completely resected or resectable primary CRC;(2)completely resectable IPNs;(3)controlled or controllable extrapulmonary metastasis;and(4)adequate general condition and pulmonary function to tolerate pulmonary operation.Lung operation was performed by a thoracic surgeon without CT-guided biopsy for pathologic confirmation.RESULTS:A total of 40 cases of lung resection was performed in 29 patients.Five patients underwent repeated lung resection.The final pathology result showed metastasis from the CRC in 30 cases(75%)and benign pathology in 10 cases(25%).The primary tumor site was the rectum in 26/30(86.6%)cases with pulmonary metastasis,but only 3/10(30%)cases in the benign group had a primary rectal cancer(P=0.001).Positron emission tomography(PET)-CT was performed for 22/30(73.4%)patients in the lung metastasis group and for 6/10(60.0%)patients in the benign group.PET-CT revealed hot uptake of18fluorine 2-fluoro-2-deoxy-D-glucose with all IPNs in both groups.The group with pulmonary metastasis had a higher incidence of primary rectal cancer(P=0.001),a more advanced tumor stage(P=0.011),and more frequent lymphatic invasion of tumor cells(P=0.005).Six cases with previous liver metastasectomy were present in the lung metastasis group.Serum carcinoembryonic antigen levels before lung operation were not elevated in any of the patients.CONCLUSION:The stage and location of the primary tumor and tumor cell infiltration of lymphatics provide useful indicators for deciding on lung resection of IPNs in CRC.     

Treatment of Cryptococcus gattii Infection Using Voriconazole

We previously reported a 39-year-old man who presented with pulmonary and cerebral Cryptococcus gattii (genotype VGIIa) infection and was successfully treated with liposomal amphotericin B and flucytosine induction therapy. Following induction therapy, oral fluconazole treatment was initiated as consolidation therapy. However, the patient complained of progressively worsening headache, presenting an elevated cerebrospinal fluid (CSF) cell count. The minimum inhibitory concentrations of the CSF isolate were 8 and 0.12 μg/mL for fluconazole and voriconazole, respectively. The oral administration of voriconazole for more than 18 months alleviated his symptoms. Voriconazole might be useful for controlling refractory cases of C. gattii infection.     

Multiple peripheral pulmonary nodules preceding rheumatoid arthritis

Summary The case of a young woman is reported, presenting multiple peripheral lung nodules, preceding the onset of classical rheumatoid arthritis 3 months later. The nodules observed seemed to be of pleural origin because they all had contact with the pleura which was partly thickened as demonstrated by computer-assisted tomography. The histopathology of material obtained by an open-lung biopsy revealed rheumatoid necrobiotic nodules. Although very rare, rheumatoid arthritis should be considered as a differential diagnosis of pulmonary nodules of unknown origin.     

Incidence of defibrillator patch infection due to pulmonary erosion

BACKGROUND: Intrathoracic defibrillator patches were used prior to effective transvenous defibrillation systems. Spontaneous erosion through the visceral pleural has been documented but the incidence has not been previously reported. METHODS: All patients who underwent insertion of ICD patches at Westmead Hospital were identified from Hospital and device company databases. Medical records were reviewed and further follow-up performed through local doctors and the National Registry of Deaths where appropriate. RESULTS: One hundred and four patients underwent insertion of ICD intrathoracic patches between 1987 and 2000. The patches were positioned adjacent to the pericardium in the pleural cavity. Eight patients died within three months of surgery and two patients developed early ICD infection. Of the other 94 patients, 40 were alive at the time of last review such that there had been 562 patient years of survival with four patients developing spontaneous patch infection. The incidence was 0.7% per patient year. The diagnosis was delayed in all four patients. All underwent removal of the ICD system with one perioperative death. CONCLUSIONS: There is a small but significant risk of late spontaneous ICD patch infection. The condition is life-threatening and the diagnosis is usually delayed.     

韦格纳肉芽肿病合并肺部感染的临床分析

目的 分析韦格纳肉芽肿病合并肺部感染的临床特点和危险因素.方法 回顾性分析北京协和医院1998-2009年收治的韦格纳肉芽肿病合并肺部感染患者的临床资料.采用t检验和Fisher检验进行统计分析.结果 92例韦格纳肉芽肿病患者中合并肺部感染27例(29％).其中首次就诊即合并肺部感染7例占26％,确诊韦格纳肉芽肿病0～6个月内发生肺部感染12例(44％),确诊韦格纳肉芽肿病6个月以上发生肺部感染8例(30％).肺部感染表现为咳嗽、咯痰(89％),咯血(63％),发热、乏力(56％),胸闷、胸痛(33％).主要为细菌感染(59％),真菌感染(37％),结核分枝杆菌感染(37％).WG合并肺部感染组有鼻窦感染( P=0.01)、低蛋白血症(P=0.03)、低免疫球蛋白血症(P=0.007)、接受激素冲击治疗(P=0.002)的比例高于无肺部感染组.结论 韦格纳肉芽肿病合并肺部感染0～6个月内发生率高,临床上表现为咳嗽、咯痰,病原学检查细菌、真菌、结核感染多见,与鼻窦感染、低蛋白血症、低免疫球蛋白血症、接受激素冲击治疗有关.     

Additional pulmonary nodules in the patient with lung cancer: controversies and challenges

The optimal management of an additional pulmonary nodule in a patient with a known primary lung cancer is unclear. Additional pulmonary nodules are often identified during pathologic evaluation after resection of a primary tumor rather than before surgery. Although correlating these pathologic data with preoperative information can be useful, their applicability to management and decision making is often limited. This article focuses on the malignant additional pulmonary nodule in the same lobe as the known primary tumor, in a different lobe in the same lung as the known primary tumor, and in the contralateral lung.     

Clinical Manifestations of Cryptococcus gattii Infection: Determinants of Neurological Sequelae and Death

Background.?Longer-term morbidity and outcomes of Cryptococcus gattii infection are not described. We analyzed clinical, microbiological, and outcome data in Australian patients followed for 12 months, to identify prognostic determinants. Methods.?Culture-confirmed C. gattii cases from 2000 to 2007 were retrospectively evaluated. Clinical, microbiological, radiological, and outcome data were recorded at diagnosis and at 6 weeks, 6 months, and 12 months. Clinical and laboratory variables associated with mortality and with death and/or neurological sequelae were determined. Results.?Annual C. gattii infection incidence was 0.61 per 10(6) population. Sixty-two of 86 (72%) patients had no immunocompromise; 6 of 24 immunocompromised hosts had idiopathic CD4 lymphopenia, and 1 had human immunodeficiency virus/AIDS. Clinical and microbiological characteristics of infection were similar in immunocompromised and healthy hosts. Isolated lung, combined lung and central nervous system (CNS), and CNS only disease was reported in 12%, 51% and 34% of the cases, respectively. Complications in CNS disease included raised intracranial pressure (42%), hydrocephalus (30%), neurological deficits (27%; 6% developed during therapy) and immune reconstitutionlike syndrome (11%). Geometric mean serum cryptococcal antigen (CRAG) titers in CNS disease were 563.9 (vs 149.3 in isolated lung infection). Patient immunocompromise was associated with increased mortality risk. An initial cerebrospinal fluid CRAG titer of ≥256 predicted death and/or neurological sequelae (P?=?.05). Conclusions.?Neurological C. gattii disease predominates in the Australian endemic setting. Lumbar puncture and cerebral imaging, especially if serum CRAG titers are ≥512, are essential. Long-term follow up is required to detect late neurological complications. Immune system evaluation is important because host immunocompromise is associated with reduced survival.     

CT引导下经皮肺穿刺在肺部病变中的应用

目的探讨CT引导下经皮肺穿刺活检在肺部病变中的应用。方法对98例肺部病变患者行CT引导下经皮肺穿刺活检,回顾性分析结果和并发症。结果恶性肿瘤确诊率为91．7％,假阴性率为8．3％,无假阳性率;良性病变确诊率为84．6％,假阴性率为15．4％;总确诊率为89．8％。并发症主要是气胸和出血,气胸的发生率为11．2％;出血的发生率为8．2％;同时有气胸和出血的为3．1％。结论CT引导下经皮肺穿刺活检术对肺部病变的诊断准确性高,并发症低。     

The value of BAL fluid LDH level in differentiating benign from malignant solitary pulmonary nodules

Purpose Serum lactate dehydrogenase (LDH) concentration is an indicator of tissue injury. It may be locally secreted in some conditions. This study was performed in order to investigate the value of LDH levels in bronchoalveolar lavage fluid (BALF) in the differentiation of a bening, from a malignant solitary pulmonary nodules (SPN) and to assess its relationship with serum LDH levels. Methods The study was a prospective clinical study. It included 59 patients with a SPN. They underwent bronchoscopy with bronchoalveolar lavage (BAL). Both total serum and BAL LDH levels were measured. Results BALF LDH level was increased in all patients with malignant SPN. The mean BALF LDH level was significantly higher in patients with malignant SPN (342.23 ± 89.98) as compared to the benign ones (17.62 ± 7.90) (P < 0.001). There was no correlation between BALF LDH and serum LDH level in patients with SPNs (P = 0.595). Conclusion BALF LDH levels are increased in patients with malignant SPN, but had no significant rise in benign SPN. This factor is useful in differentiating the benign SPNs from malignant SPNs.     

Computed tomographic scan evaluation of pulmonary blastomycosis

BACKGROUND:

Blastomycosis is an uncommon granulomatous pulmonary and extrapulmonary infectious disease caused by the thermally dimorphic fungus Blastomyces dermatitidis. Diagnosis may be delayed or difficult because of varied presentation. The characteristics of blastomycosis on computed tomographic (CT) scan of the chest are not well characterized.

METHODS:

The images from 34 chest CT scans from patients with confirmed pulmonary blastomycosis were retrospectively reviewed.

RESULTS:

The most common CT findings were air bronchograms in 22 patients (65%), consolidation in 21 patients (62%), nodules (smaller than 3 cm) in 21 patients (62%) and lymph node enlargement (mediastinal and hilar nodes combined) in 12 patients (35%). Only four patients (12%) had a miliary pattern.

CONCLUSIONS:

A specific abnormality characteristic of pulmonary blastomycosis was not identified on CT scanning. The diagnosis can only be made in the context of a high index of clinical suspicion with histological or culture confirmation.     

SXI2a基因在新生和格特隐球菌交配型鉴定中的作用

目的设计针对a交配型位点内特有的SXI2a基因的特异扩增法,评价其在鉴定新生和格特隐球菌所有主要基因型a交配型中的作用。方法在SXI2a基因4号外显子的序列保守区设计引物SXI2aF-SXI2aR特异扩增新生和格特隐球菌a交配型,并比较其与现有的针对STE20a、MFa或STE3a基因的特异扩增法及交配试验在鉴定新生和格特隐球菌所有主要基因型a交配型中的作用。结果针对SXI2a基因的特异扩增法准确鉴定受试的各主要基因型a交配型菌株,而针对STE20a、MFa或STE3a基因的特异扩增法均至少无法扩增1种以上主要基因型的a交配型。部分受试菌株不能发生交配,交配试验无法鉴定其交配型。结论针对SXI2a基因的PCR扩增可鉴定新生和格特隐球菌各主要基因型的a交配型。SXI2aF-SXI2aR引物在快速鉴定a交配型中具有更好的通用性和特异性。     

Cryptococcus neoformans in tropical northern Australia: predominantly variant gattii with good outcomes

Background: Infection with Cryptococcus neoformans is common in the Northern Territory of Australia. Disease is life threatening and treatment is prolonged and often complicated by the need for surgery and difficulties with medical therapy. Aims: To document incidence, demography, risk factors, clinical features and outcomes of infection and to determine differences between gattii and neoformans varieties. Methods: Case records of all patients (n= 35) diagnosed with cryptococcal infection at the Royal Darwin Hospital between 1976 and 1992 were reviewed retrospectively. Current status of patients was ascertained. Variety identification of isolates was determined by growth in canavanine-glycine-bromthymol blue agar. Results: Of the 35 patients, 23 had meningitis, ten had pneumonia, one had a dermal infection and one had fungaemia with no obvious focus. Twelve (52%) meningitis cases and two (20%) pneumonia cases had no predisposing disease. Thirteen (57%) meningitis cases had concomitant pulmonary cryptococcosis. Twenty-nine patients were Aboriginal and six were Caucasian, with a relative risk for Aboriginals compared with non-Aboriginals of 20.6 (95% CI 8.6–49.5). Arnhem-land was the commonest location of infection, with an annual incidence in Aboriginals of 0.14/1000. Fourteen (78%) of 18 isolates tested were C. neoformans var. gattii. Management was characterised by the frequent need for adjunctive surgery and prolonged or repeat courses of systemic antifungal therapy. Despite this, long-term outcomes are encouraging with a mortality of 14% overall and 9% in meningitis patients. The river red gum (Eucalyptus camaldulensis) has a limited distribution in Arnhemland and ongoing studies are seeking alternative environmental sources of C. neoformans var. gattii. (Aust NZ J Med 1993; 23: 678–682.)     

胸腔镜肺段切除术治疗肺部疾病的临床疗效分析

目的探讨胸腔镜肺段切除术在肺部疾病治疗过程中的安全性、可行性及有效性。方法选取2011年1月~2013年12月安徽省立医院胸外科34例接受胸腔镜肺段切除术患者。回顾性分析临床资料,统计患者的手术时间、术中出血量以及术后并发症的发生情况。结果 34例患者均成功施行胸腔镜肺段切除术,平均手术时间(119.6±53.2)min,术中平均出血量(90.0±52.3)ml,术后平均留置胸引管时间(5.1±1.2)d,术后平均住院时间(6.2±1.9)d,无围手术期死亡病例,术后再次手术1例,持续性肺漏气≥7 d 2例,肺不张1例,均经保守治疗治愈。结论胸腔镜肺段切除术在治疗肺部良性疾病及早期肺癌方面是安全可行的,术中出血量较少,术后留置胸引管时间及术后住院时间短,手术时间及术后并发症并不相应增加。     

Cryptococcus gattii infection in solid organ transplant recipients: description of Oregon outbreak cases

Cryptococcus gattii was recognized as an emerging infection in the Pacific Northwest in 2004. Out of 62 total infections in Oregon since the outbreak, 11 were in solid organ transplant (SOT) recipients. SOT recipients were more likely to have disseminated disease and higher mortality than normal hosts, who mostly had isolated mass lesions. The median time from transplantation to C. gattii diagnosis was 17.8 months. The primary sites of infection were lung (n = 4), central nervous system (n = 3), or both (n = 4). The Oregon‐endemic strain, VGII (subtypes IIa and IIc) was present in 10 of 11 patients; the median fluconazole minimum inhibitory concentration (MIC) was 12 μg/mL (range 2–32 μg/mL) for this strain. We found C. gattii infection among organ transplant recipients was disseminated at diagnosis, had low cerebrospinal fluid cryptococcal antigen titers, and was associated with an elevated fluconazole MIC and high attributable mortality.