Disseminated cryptococcosis with caverno-oesophageal fistula in a case of idiopathic CD4+ T-lymphocytopenia.

Idiopathic CD4+ T-Lymphocytopenia is a rare immunodeficiency disorder characterised by significantly low absolute CD4 lymphocytes in absence of any viral infections. We present a case of Disseminated Cryptococcosis with Caverno- Oesophageal Fistula in a case of Idiopathic CD4+ T-Lymphocytopenia. 29 year old lady was referred to Institute in view of lung mass not responding to anti-TB treatment. Subsequently patient had developed headache. Radiological evaluation showed presence of ring enhancing lesion in the occipital region. On evaluation with Fibre-optic bronchoscopy, there was no evidence of malignancy or tuberculosis. Sputum showed presence and growth of Cryptococcus neoformans. Patient's investigations were negative for virus infection, with normal immunoglobulin levels. Her CD4 counts were 129 cells/mm3. Patient was treated with injectable antifungals. Patient developed a Caverno-oesophageal fistula which was confirmed on endoscopy and radiology. Patient was managed with percutaneous jejunal feeding (PEJ). Patient improved symptomatically with CD4 count of 475 cells/mm3.

Serial lobar lung lavage in pulmonary alveolar proteinosis.

Pulmonary alveolar proteinosis (PAP) is a rare disease with worldwide distribution and an estimated incidence of 0.36 cases per million. We report a case of a PAP coexisting with Pneumocystis jiroveci pneumonia and Mycobacterium tuberculosis infection. The patient was treated with serial lobar lung lavages, GM-CSF, cotrimoxazole, and antituberculosis drugs. His PaO2 on room air improved from 45.7 to 63.8 torr and pulmonary functions normalized (FVC 81.2%, FEV1 95.3%, FEV1/FVC 91.8). A high-resolution computed tomography scan of the thorax showed clearing of both lower lobes. Whole-lung lavage is used in the treatment of PAP, but it may worsen the hypoxemia and lead to hemodynamic instability during the procedure. To the best of our knowledge, there are no reports of bronchoscopic serial lobar lung lavages in cases of PAP performed in India. This method can be performed in bronchoscopic suites having general anesthesia facilities without the requirement of special gadgets.