MKSAP: 45-year-old man with cough and right-sided chest discomfort

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 45-year-old man is evaluated for right-sided chest discomfort and cough of 2 weeks’ duration. His chest discomfort is described as a vague, painful sensation on the right. The cough occasionally produces a small amount of sputum; he reports no hemoptysis or shortness of breath. He has felt feverish with mild fatigue but has had no weight loss. He is a smoker with a 20-pack-year history. He takes no medications.

On physical examination, temperature is 37.6 °C (99.7 °F), blood pressure is 130/70 mm Hg, pulse rate is 86/min, and respiration rate is 18/min. BMI is 27. Oxygen saturation breathing ambient air is 98%. Chest examination is normal, and the remainder of the physical examination is unremarkable. No skin rash is present.

Chest radiograph shows a nodule in the right lower lung lobe, which CT of the chest confirms. CT-guided biopsy of the nodule is performed. Findings on histologic testing are positive for budding yeast, and culture indicates Cryptococcus neoformans.

An HIV test result is negative.

Which of the following is the most appropriate management?

A: Caspofungin
B: Lumbar puncture
C: Surgical removal of the nodule
D: Clinical observation

MKSAP Answer and Critique

The correct answer is B: Lumbar puncture.

This patient has pulmonary cryptococcosis and should undergo lumbar puncture. Whenever Cryptococcus is found at a site outside of the central nervous system (CNS), a lumbar puncture should be performed to determine whether CNS infection is also present, even in the absence of CNS symptoms. Patients who are immunocompromised or become immunocompromised following primary infection are at risk for more progressive infection or disseminated infection.

The echinocandins, such as caspofungin, have no activity against Cryptococcusand, therefore, play no role in therapy for pulmonary cryptococcosis.

Removal of the pulmonary nodule is not indicated at this time. If radiologic abnormalities and symptoms persist despite antifungal therapy, then surgery should be considered. Because of this patient’s smoking history, further histologic investigation might be appropriate if his lung findings do not improve following therapy.

In immunocompetent patients, infection may resolve spontaneously, remain stable for a prolonged duration, or become progressive. Although most immunocompetent patients with primary pulmonary cryptococcosis may be asymptomatic and their infection may resolve without treatment, treatment is indicated to prevent progressive or disseminated disease and usually consists of daily fluconazole for 6 to 12 months. Therefore, providing no additional treatment would not be appropriate.

Key Point

  • In patients with pulmonary cryptococcosis, lumbar puncture should be performed to determine if central nervous system (CNS) infection is also present, even in the absence of CNS symptoms.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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