[A case of secondary pulmonary cryptococcosis presenting with multiple cystic shadows].

An 80-year-old woman with a history of rheumatoid arthritis and steroid diabetes had been given a diagnosis of multiple bilateral pulmonary cystic lesions 16 months previously, and these lesions were observed to gradually increase on follow-up. She presented with a fever of 38 degrees C, cough, and sputum for 2 weeks, and the pulmonary cystic lesions had enlarged, and therefore she was admitted. A chest X-ray film revealed multiple cystic lesions 4 cm in greatest dimension in both the left upper and middle lung fields, and chest computed tomography (CT) scans revealed that the lesions of the left S1+2 had niveau formation with a partially thickened wall. However, the lesions in the left S4 and S5 areas and the right S8 area had thin, smooth walls. Transbronchial lung biopsy of the left S4 lesion yielded granuloma formation and yeast-like fungus bodies within multinucleated giant cells, while bronchial lavage fluid culture showed cryptococcus neoformans. It is known that pulmonary cryptococcosis presents various images and histopathologic findings, according to the immune interactions between the fungus body and the host. We report a rare case that presented with multiple cryptococcal cystic lesions.

[A case of pulmonary tuberculosis with multiple pneumatoceles in adult].

We describe a 32-year-old woman suspected of having pulmonary tuberculosis due to abnormal shadows found on her chest x-ray in a community health examination in September 2002. However, she consistently refused further examinations and treatment. In January 2005, she complained of a cough and sputum, by October she developed diarrhea, and by December a sore throat and fever. She was admitted to our hospital on January 23, 2006. Her chest radiograph revealed multiple thin-walled cystic lesions and infiltrative shadows in both upper lobes of the lung, a giant thin-walled cystic lesion in the superior segment of the left lower lobe, and diffuse particulate shadows. Since acid-fast staining of her sputum smear and a PCR test to detect tubercle bacilli both were positive, a diagnosis of pulmonary tuberculosis was made and we treated her with antituberculotic agents. Ten days after starting the treatment, her cystic lesions decreased or disappeared. Although she was seemingly healthy, her pulmonary tuberculosis became more severe since she failed to follow her treatment regimen. She therefore developed nutritional disorders and cellular immunity dysfunction that induced a sequence of changes, e.g. poor granuloma formation, excaration of caseous necrofic material by draining bronchi, and a check-valve mechanism. We speculate that these symptoms caused the formation of pneumatoceles. To our knowledge, this is the first case of pneumatocele formation found in a patient with pulmonary tuberculosis reported in Japan.