Disseminated cryptococcal infection with pulmonary involvement presenting as diffuse cavitary nodules in an immunocompromised patient: a case report.

BACKGROUND: Disseminated cryptococcal infection is especially prone to occur in immunosuppressed hosts. We herein report the case of an immunosuppressed girl with disseminated cryptococcal infection in whom pulmonary cryptococcosis (PC) presented as diffuse cavitary pulmonary nodules, a finding which has rarely been reported. CASE PRESENTATION: A 16-year-old immunocompromised girl presented with fever and a non-productive cough. A chest computed tomography (CT) scan revealed diffuse pulmonary nodules with cavities. Subsequent results were consistent with disseminated cryptococcosis with Cryptococcus identified in her blood, bone marrow and cerebrospinal fluid cultures. Thus, the patient was diagnosed with disseminated cryptococcal infection with PC, cryptococcus meningitis, cryptococcus osteomyelitis and cryptococcus sepsis. After antifungal treatment, the patient demonstrated both clinical and chest radiological improvement. CONCLUSION: The atypical clinical manifestations of a disseminated cryptococcal infection and the rare manner of chest CT findings of PC reported in our case are easy to misdiagnose. It is necessary to carry out a thorough search for a definitive diagnosis using various methods.

Pulmonary Co-infection with Cryptococcus Species and Pneumocystis jirovecii in an Old Patient Without a Previous Predisposing Illness.

BACKGROUND: Cryptococcosis and pneumocystosis are opportunistic infections which are more common in immunosuppressed individuals. Herein, we report a rare case of coinfection of pulmonary cryptococcosis (PC) and Pneumocystis jirovecii pneumonia (PJP) in a patient without a previous predisposing illness. Case presentation A 76-year-old man was admitted to our hospital with complaints of cough, expectoration, shortness of breath, and fever. A chest computed tomography (CT) showed multiple nodules with diffuse ground-glass opacities (GGOs) in both lungs. The patient was diagnosed as extrinsic allergic alveolitis (Pigeon breeder's lung). After treatment with corticosteroids, the patient improved with significant absorption of GGOs on chest CT. However, pulmonary nodules gradually enlarged and such lesions could not be explained by EAA. Based on the positivity of serum cryptococcal antigen and pathological examination of lung nodule which confirmed the presence of Cryptococcus spores, PC was diagnosed later and fluconazole was administered. However, repeated chest CT performed about 2 months after antifungal treatment showed significantly increased GGOs in both lungs. The pathological examination of new lung lesions revealed the presence of P. jirovecii. The patient was finally diagnosed having coinfection of PC and PJP and sulfamethoxazole was further prescribed. Thereafter, the patient improved again with significant absorption of GGOs as noted on chest CT. CONCLUSIONS: Concomitant PC and PJP is very rare, especially in a patient without a previous predisposing illness. Additionally, when pulmonary lesions cannot be completely explained by one kind of infectious disease, the possibility of mixed infection should be considered.

Convalescent plasma therapy for patients with severe COVID-19: A case series study.

Coronavirus disease 2019 (COVID-19) is a novel acute respiratory infectious disease that can lead to multiple-organ dysfunction in patients with severe disease. However, there is a lack of effective antiviral drugs for COVID-19. Herein, we investigated the efficacy and safety of convalescent plasma (CP) therapy for treating severe COVID-19 in an attempt to explore new therapeutic methods. The clinical data of 3 imported patients with severe COVID-19 who underwent treatment with CP and who were quarantined and treated in a designated COVID-19 hospital from March 2020 to April 2020 were collected and analyzed. The 3 patients, including a 57-year-old male, 65-year-old female, and 59-year-old female, were clinically classified as having severe COVID-19. The main underlying diseases included hypertension, diabetes, sequelae of cerebral infarction, and postoperative thyroid adenoma. The common symptoms included cough, fever, and shortness of breath. All patients received antiviral drugs and other supportive treatments. Additionally, CP treatment was administered. At 48 to 72 hours after the CP transfusion, all 3 of the patients exhibited an improvement and alleviation of symptoms, an elevated arterial oxygen saturation, and decreased C-reactive protein and interleukin-6 levels. The counts of the total lymphocytes and T lymphocytes (CD3+) and their subsets (CD4 + and CD8+) were also obviously increased. Repeated chest computed tomography also revealed obvious absorption of the lesions in the bilateral lungs. Only 1 patient had a mild allergic reaction during the CP infusion, but no severe adverse reactions were observed. The early treatment with CP in patients with severe COVID-19 can rapidly improve the condition of the patients, and CP therapy is generally effective and safe.

Prolonged SARS-Cov-2 shedding with rapid IgG antibody decay in a COVID-19 patient: A case report.

BACKGROUND: The coronavirus disease 2019 (COVID-19) epidemic is still spreading rapidly around the world. Recent cases with prolonged severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA detection have been successively reported, and the phenomenon of false-negative real-time polymerase chain reaction (RT-PCR) results of SARS-CoV-2 RNA or "repositive" was also described in COVID-19 patients. METHODS: We report a 69-year-old female patient with hypertension, suspected lung tumor, and previous history of total hysterectomy for hysteromyoma who presented with moderate COVID-19 symptoms and was positive for SARS-CoV-2 RNA by RT-PCR when she traveled from the USA to China. RESULTS: The patient required second and third re-hospitalizations due to "repositive" SARS-CoV-2 throat swab test results during post-charge solitary isolation and observation, and serum SARS-CoV-2-IgG decayed rapidly before disappearing on illness Day 139 when the throat swab was still positive. The virus shedding lasted for at least 146 days (the last positive throat swab test result was on illness Day 146, and the first true-negative test result was on illness Day 151) since her initial positive test. CONCLUSION: Prolonged SARS-CoV-2 RNA viral shedding is prone to occur in an immunocompromised host, wherein changes in the host immune status can lead to repeated positive SARS-CoV-2 detection. Moreover, the SARS-CoV-2-IgG may decrease rapidly and disappear before virus removal, indicating there may be certain limitations on the protective effect of the SARS-CoV-2 antibody, which deserves clinical attention.

Concomitant lung adenocarcinoma and pulmonary cryptococcosis confirmed by pathologic examinations.

To describe the characteristics of concomitant lung cancer and pulmonary cryptococcosis (PC) cases.A total of 8 patients with lung cancer and coexisting PC, who were admitted to Fuzhou Pulmonary Hospital of Fujian from 1st January 2009 to 31st December 2015 and whose diagnoses were confirmed by pathological examinations, were studied.One patient had a history of diabetes mellitus and 1 had a history of treated with surgery. The lesions in 7 cases manifested as nodular shadows; only 1 case showed the lesion of the 2 diseases mergedmixed together, and it manifested as a large flake-like infiltrated shadow in the same lobe. The histological type in all of the patients was lung adenocarcinoma. Lung cancer stage was advanced (III-IV) in 25.0% of the cases. The 5 patients who received surgery and drug treatment are presently healthy following resection. Recurrence and metastasis of lung cancer following surgery occurred in 2 patients in whom the tumor was controlled again after anti-tumor treatment. One patient with advanced lung cancer and PC was treated with antifungal therapy in combination with antineoplastic chemotherapy, but she failed to improve and died 10 months after symptom onset during the follow-up period.PC coexisting with pulmonary carcinoma is rare. PC can manifest as pulmonary nodules and mimic malignant lesions, so it must be considered during a differential diagnosis of pulmonary nodules, especially in immunosuppressed patients.

First successful combination of extracorporeal membrane oxygenation (ECMO) with video-assisted thoracic surgery (VATS) of pulmonary bullae resection in the management of refractory pneumothorax in a critically ill patient with H7N9 pneumonia and acute respiratory distress syndrome: A case report.

RATIONALE: At present, data regarding refractory pneumothorax treated with video-assisted thoracic surgery (VATS) in combination with extracorporeal membrane oxygenation (ECMO) in critically ill patients with H7N9 pneumonia have never been reported. PATIENT CONCERNS: A laboratory-confirmed case of human infection with avian influenza A (H7N9) virus was treated in our hospital. Acute respiratory distress syndrome (ARDS) developed and the patient was oxygenated via veno-venous ECMO due to the failure of mechanical ventilation. Unfortunately, a right refractory pneumothorax occurred. Despite treatment with pleural drainage and select bronchial occlusion, the patient still failed to improve. DIAGNOSIS: Fatal H7N9 pneumonia complicated with severe ARDS, pulmonary bullae, and refractory pneumothorax. INTERVENTIONS: Successful combination of ECMO with VATS of pulmonary bullae resection was performed and pneumothorax was cured. OUTCOMES: One week after the operation, ECMO was removed. However, the patient finally developed multiorgan failure (MOF) complicated by refractory hypoxemia due to progressive lung fibrosis and died 36 days after admission. LESSONS: Although the patient died of MOF triggered by severe lung fibrosis at last, the successful treatment of refractory pneumothorax by combination of ECMO with VATS is encouraging. Thus, when refractory pneumothorax in a patient with severe pulmonary dysfunction fails to improve through routine therapy, the treatment of pneumothorax by VATS based on ECMO support can be considered as a feasible selection.

Concomitant severe influenza and cryptococcal infections: A case report and literature review.

Concomitant influenza and cryptococcal infections are rare. Herein, we describe an unusual case of an avian influenza A (H7N9) infection with several severe mixed bacterial infections and systemic super-infection with Cryptococcus neoformans presenting as ventilator-associated pneumonia (VAP) and bloodstream infection in a previously immunocompetent man during hospitalization.A 58-year-old man was admitted to our hospital complaining of hyperpyrexia, dyspnoea, cough, and phlegm with blood. A chest computed tomography scan revealed multiple ground-glass opacities and consolidation in both lungs with right pleural effusion. An initial sputum test was positive for influenza A (H7N9) virus. After antiviral treatment and other supportive measures, the patient's condition improved. However, the patient's condition deteriorated again approximately 2 weeks after admission, and bronchoalveolar lavage fluid (BALF) and blood cultures were positive for C. neoformans. Therapy with intravenous liposomal amphotericin B and fluconazole was started. After a 2-week antifungal treatment, BALF and blood cultures were negative for C. neoformans. However, the patient had persistent lung infiltrates with severe pulmonary fibrosis with a prolonged course of disease. On hospital day 40, BALF and blood cultures were both positive for multidrug-resistant Stenotrophomonas maltophilia. Finally, the patient developed septic shock, disseminated intravascular coagulation and multi-organ failure and succumbed to treatment failure.Cryptococcal infection can occur in patients with severe influenza during hospitalization with a more severe condition, and the clinician should be aware of this infection.

Comparison of patients with avian influenza A (H7N9) and influenza A (H1N1) complicated by acute respiratory distress syndrome.

The aim of this study was to compare the clinical features of patients with avian influenza A (H7N9) and influenza A (H1N1) complicated by acute respiratory distress syndrome (ARDS).The clinical data of 18 cases of H7N9 and 26 cases of H1N1 with ARDS were collected and compared in the respiratory intensive care unit (RICU) of Fuzhou Pulmonary Hospital of Fujian from March 2014 to December 2016.Patients with H7N9 had a higher acute physiology and chronic health evaluation-II score (P < .05) and lung injury score (P < .05). The rates of coexisting diabetes mellitus, hyperpyrexia, and bloody sputum production were significantly higher in the H7N9 group than in the H1N1 group (P < .05). The H7N9 group had a longer duration of viral shedding from the onset of illness (P < .05) and from the initiation of antiviral therapy (P < .05) to a negative viral test result than the H1N1 group. Patients with H7N9 had higher rates of invasive mechanical ventilation; serious complications, including alimentary tract hemorrhage, pneumothorax or septum emphysema, hospital-acquired pneumonia (HAP) and multiple organ dysfunction syndrome (MODS); and hospital mortality (P < .05). At the 6th month of follow-up, the rates of bronchiectasia, reticular opacities, fibrous stripes, and patchy opacities on chest computed tomography (CT) were significantly higher in the H7N9 group than in the H1N1 group (P < .05). Based on multiple logistic regression analysis, H7N9 influenza viral infection was associated with a higher risk of the presence of severe ARDS than H1N1 influenza viral infection (odds ratio 8.29, 95% confidence interval [CI] 1.53-44.94; P < .05).Compared to patients with H1N1, patients with H7N9 complicated by ARDS had much more severe disease. During long-term follow-up, more changes in pulmonary fibrosis were observed in patients with H7N9 than in patients with H1N1 during the convalescent stage.

Histopathological findings in a critically ill patient with avian influenza A (H7N9).

To date, data regarding the pulmonary histopathology of human H7N9 disease are scarce. We herein describe a patient with a severe case of avian influenza A (H7N9). A chest computerized tomography (CT) scan showed diffuse ground-glass opacities and consolidation throughout the lungs. A resection of pulmonary bullae in the right middle lobe was performed by video-assisted thoracic surgery (VATS) based on the extracorporeal membrane oxygenation (ECMO) supportive technique on the 23(rd) day after the onset of symptoms because of a right pneumothorax persistent air leak. The histopathological findings of the resected lung tissue revealed pneumocyte hyperplasia and fibroproliferative changes along with diffuse alveolar damage. Bronchoalveolar lavage fluid (BALF) specimens for influenza A (H7N9) virus were continuously positive for more than three weeks, despite oseltamivir treatment, and continuous viral replication significantly prolonged the course of the disease. The patient's clinical status continuously deteriorated, with the development of refractory hypoxemia due to progressive and rapid lung fibrosis, which was confirmed by the final histological changes observed from a limited post-mortem biopsy of lung tissue. Pre-terminally, he developed multi-organ failure and died on the 39(th) day after symptom onset, despite corticosteroid treatment.