Pleural Effusion as the Initial Clinical Presentation in Pulmonary Cryptococcosis: A Report of a Case with Unusual Manifestation, and a Literature Review

以肋膜腔積液為表現之肺部新形隱球菌感染：病例報告及文獻回顧

謝佳龍(Chia-Loung Hsieh) ； 江啟輝(Chi-Huei Chiang) ； 彭瑞鵬(Reury-Perng Perng)

《胸腔醫學》 18卷6期 (2003/12) Pp. 500-506

https://doi.org/10.29806/TM.200312.0004

摘要

肺部新形隱球菌感染是一不常見的黴菌感染症。由於其症狀較不具特異性，病原體不易由肺部分泌物培養出來，且其影像學上會有許多種不同的表現，因此診斷上相對來說較為困難。雖然免疫功能不全的病患對罹患此病會有較高的危險性，它也會發生在免疫功能正常的病人身上。以免疫功能正常的病患來說，肺部的侵犯主要有三種形式：肺部結節，間質性浸潤，以及肺實質性病變。以肋膜積液來表現者極為罕見。
在此我們報告一個病例：他是一個結核性肋膜炎合併有胸壁結核菌感染的患者，經過完整的抗結核藥物治療，肋膜積液已完全消失。兩年後，肋膜積液再度出現，初步門診臆斷為肺結核復發或是肺腺癌合併肋膜積水。患者住院接受超音波導引肋膜液抽取術。肋膜液細胞學檢查高度懷疑為新形隱球菌感染，但仍不能排除結核性肋膜炎。患者並接受手術。手術取下之組織病理報告為酵母菌狀微生物且排除肺結核。因患者使用amphotericin-B後出現副作用，因此以fluconazole治療。
台灣疾病型態愈來愈像歐美，隱球菌感染較以前常見，所以今提出此罕見之病例，可讓臨床醫師對於肋膜積液鑑別診斷之參考。

關鍵字

新形隱球菌 ； 肋膜腔積液

並列摘要

The diagnosis of the pulmonary cryptococcosis is relatively difficult. This is due to its nonspecific symptoms and usually negative culture results, the low sensitivity of the serum cryptococcal antigen test, and the wide variety of radiological appearances. Although immunocompromised patients are at the highest risk, it may occur in patients with normal immunity. In immunocompetent patients with pulmonary cryptococcosis, several radiographic patterns are exhibited, including pulmonary nodules, interstitial infiltrations, and consolidation. Pleural effusion rarely occurs in immunocompetent patients.
This patient was a victim of pulmonary tuberculosis (TB) complicated with pleural effusion and chest wall involvement. After complete anti-TB treatment, the pleural effusion disappeared. Unfortunately, 2 years later, right-side pleural effusion recurred and a loss of body weight was also noted. The initial impressions were 1, pulmonary TB reactivation complicated with pleural effusion; and 2, adenocarcinoma of the lung with pleural effusion. Sono-guided thoracocentesis was performed. Cytology examinations of the pleural fluid showed highly suspected cryptococcus infection, but the cryptococcal antigen test showed negative. He underwent a video-assisted thoracoscopic decortication for further diagnosis, and treatment for fibrothorax. The pathology of the tissue from decortication showed yeast-like microorganisms. Due to the renal impairment after amphotericin B treatment, he received fluconazole therapy, and regularly followed up in the outpatient department. After antifungus treatment, he gained weight and felt better than before. Based on this unusual presentation of cryptococcosis, physicians should consider the possibility of cryptococcosis of the lung complicated with pleural effusion in the differential diagnosis of chronic pleural effusion in Taiwan.

並列關鍵字

cryptococcosis ； pleural effusion