Rapidly enlarging pulmonary mass due to immune reconstitution inflammatory syndrome (IRIS) in an immunocompetent host with pulmonaryCryptococcus neoformans

Abstract

An immunocompetent man presented with Cryptococcus neoformans disease manifesting as a large pulmonary mass (cryptococcoma). Despite an initial induction course of 4 weeks of liposomal amphotericin B (LAmB), followed by 8 weeks of fluconazole, the cryptococcoma enlarged in size. Ten days into a second course of induction therapy with LAmB and flucytosine, the cryptococcoma markedly increased in size with encroachment on critical vascular structures. Due to concern for immune reconstitution inflammatory syndrome (IRIS), prednisone was added with significant decrease in the size of the mass. To our knowledge, this is the first reported case of pulmonary cryptococcal-IRIS in an immunocompetent host.

Criptococoma pulmonar gigante en paciente inmunocompetente

“…The invasive infections by Cryptococcus neoformans or Cryptococcus gattii more frequently involve the lungs and the central nervous system (CNS) with a high mortality rate; besides, the muscles, skeletal, skin and soft tissues, abdominal viscera, eyes, and prostate of both previous healthy and immunosuppressed individuals may be affected. [1][2][3][4][5] More often, C. gattii causes mass lesions in CNS, while C. neoformans does it in lungs. 2 Risk factors include HIV/AIDS, solid organ transplant, immunomodulatory agents, liver cirrhosis, chronic renal disease, diabetes mellitus, malignancy, and autoimmune disease.…”

“…4 Tucker M et al also reported the development of IRIS in an immunocompetent male patient with rapidly enlarging cryptococcoma by C. neoformans that compressed vascular structures in spite of the four weeks of amphotericin B plus eight weeks of fluconazole. 5 The critical consequences of vascular encroachment were responsive to prednisone, and authors stressed that this was the first cryptococcal-IRIS in an immunocompetent host. 5 Finally, Brazilian authors described the findings of complete necropsy study of a 32-year-old man who died due to the acquired immunodeficiency syndrome (AIDS) and systemic mycobacteriosis, and presented with an unsuspected restrained prostatic cryptococcoma.…”

“…5 The critical consequences of vascular encroachment were responsive to prednisone, and authors stressed that this was the first cryptococcal-IRIS in an immunocompetent host. 5 Finally, Brazilian authors described the findings of complete necropsy study of a 32-year-old man who died due to the acquired immunodeficiency syndrome (AIDS) and systemic mycobacteriosis, and presented with an unsuspected restrained prostatic cryptococcoma. 1 The prostatic lesion measured 2 cm in diameter with numerous forms of C. neoformans; worthy of note, this agent was not found in any other site, contrasting with mycobacteria miliary dissemination detected in the lungs, spleen, liver, adrenals, and lymph nodes.…”