Pulmonary Cryptococcosis in a Patient with Ankylosing Spondylitis treated with Etanercept

Chae Ho Lim; Sang-Heon Lee; Ho-Youn Kim; Wan Seop Kim; Seonghui Kang; Se Woong Kwon; Jiwan Kim; Soo-Youn Park; Sang Hee An; Hyung Min Yu; Hae-Rim Kim

doi:10.4078/jrd.2014.21.4.214

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Lim, Lee, Kim, Kim, Kang, Kwon, Kim, Park, An, Yu, and Kim: Pulmonary Cryptococcosis in a Patient with Ankylosing Spondylitis treated with Etanercept

Case Report

J Rheum Dis 2014;21(4):214-218.

Published online: 31 October 2014

DOI: https://doi.org/10.4078/jrd.2014.21.4.214

Pulmonary Cryptococcosis in a Patient with Ankylosing Spondylitis treated with Etanercept

Chae Ho Lim¹, Sang-Heon Lee², Ho-Youn Kim², Wan Seop Kim³, Seonghui Kang¹, Se Woong Kwon¹, Jiwan Kim¹, Soo-Youn Park¹, Sang Hee An¹, Hyung Min Yu¹, Hae-Rim Kim²

¹Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea

²Division of Rheumatology, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea

³Department of Pathology, Konkuk University School of Medicine, Seoul, Korea

Corresponding to: Hae-Rim Kim, Division of Rheumatology, Department of Internal Medicine, Konkuk University Medical Center, 120-1, Neungdong-ro (Hwayang-dong), Gwangjin-gu, Seoul 143-729, Korea. E-mail: kimhaerim@kuh.ac.kr.

Received 12 August 2013 Revised 11 October 2013 Accepted 11 October 2013

This is a Free Access article, which permits unrestricted non-commerical use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Ankylosing spondylitis (AS) is a chronic inflammatory disorder, commonly characterized by inflammation of axial skeleton and development of enthesopathies. Tumor necrosis factor inhibitors (TNFi) shows good therapeutic responses in AS patients without good response to nonsteroidal anti-inflammatory drugs. Although TNFi are relatively safe for AS patients, serious opportunistic infections, including tuberculosis and fungal infection, could develop. Here, according to our knowledge, we report a first Korean case of pulmonary cryptococcosis in a patient with AS treated with etanercept. A 64 year-old man with AS visited due to a newly appeared pulmonary nodule on a routine chest radiography. He had been administered etanercept for 5 months. Histologic findings of the lung nodule showed characteristic features of cryptococcosis. Etanercept was discontinued and oral fluconazole was administrated, as there was no evidence of central nervous system involvement. After 7 months of treatment, chest CT showed an improvement of the pulmonary lesion.

Keywords: Ankylosing spondylitis, Pulmonary cryptococcosis, Etanercept, Tumor necrosis factor inhibitor

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Figure 1.

Chest radiograph showed a newly appeared solitary nodule (arrow) in the left lower lung (A) compared with a chest radiograph taken a year ago (B).

Figure 2.

Computed tomography (CT) of the lung showed an 18 mm-sized nodule with irregular margins (arrow) in left lower lobe (A). After 7 months with fluconazole treatment, follow up CT showed reduced size of the pulmonary nodule (long arrow) and newly developed ground grass opacity in right middle lobe (short arrow) (B).

Figure 3.

Histologic finding of pulmonary nodule showed fibrohistiocytic reaction with numerous bubbly microcystic organisms (A, Hematoxylin & Eosin, ×200). The organisms were highlighted by the mucicarmine stain (B, ×1,000), and Gomori-Grocott methenamine silver stain (C, ×1,000)

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