[A well-inked pneumonia… can you decrypt it?]
BACKGROUND
We report a case of pneumonia associated with necrotic mediastinal lymph nodes in an immunocompetent patient. The case report illustrates the difficulties in making a diagnosis in necrotic mediastinal lymph nodes and discusses strategies to optimize sampling.


METHODS
A 21-year-old immunocompetent woman was admitted to hospital with dyspnea and fever occurring ten days after delivery. Physical examination, biological results and chest X-ray led to the diagnosis of right upper lobe pneumonia. Treatment with three broad-spectrum antibiotics was ineffective. Thoracic CT-scan showed compressive mediastinal and hilar necrotic adenopathies and consolidation of the right upper lobe. Bronchoscopy with bronchoalveolar lavage and transbronchial needle aspiration was non-diagnostic. A second bronchoscopy with bronchoalveolar lavage and transbronchial needle aspiration performed in close collaboration with the mycology laboratory led to the diagnosis of cryptococcosis. Antifungal therapy with fluconazole resulted in a complete resolution of clinical and radiological signs.


CONCLUSIONS
Although it is extremely rare, pulmonary cryptococcosis should be considered in immunocompetent patients presenting with necrotic pneumonia. Effectiveness of lymph node sampling can be improved by collaboration between clinicians and microbiologists.
Service de pneumologie et immunoallergologie, centre de compétence des maladies pulmonaires rares, université de Lille, CHU de Lille, 59000 Lille, France.
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Tetart
Service de pneumologie et réanimation médicale, groupe hospitalier Pitié-Salpêtrière-Charles-Foix, AP-HP, 75013 Paris, France.
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Trosini-Désert
Service de mycologie et parasitologie, groupe hospitalier Pitié-Salpêtrière-Charles-Foix, AP-HP, 75013 Paris, France.
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Fekkar
Service de pneumologie et immunoallergologie, centre de compétence des maladies pulmonaires rares, université de Lille, CHU de Lille, 59000 Lille, France; Service de pneumologie et réanimation médicale, groupe hospitalier Pitié-Salpêtrière-Charles-Foix, AP-HP, 75013 Paris, France. Electronic address: cecile.chenivesse@chru-lille.fr.
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Chenivesse
D003453:Cryptococcosis / Q000150:complications / Q000473:pathology; D005260:Female; D006801:Humans; D007121:Immunocompetence; D000072281:Lymphadenopathy / Q000150:complications / Q000382:microbiology / Q000473:pathology*; D008482:Mediastinum / Q000382:microbiology / Q000473:pathology*; D009336:Necrosis; D011014:Pneumonia / Q000150:complications / Q000382:microbiology / Q000473:pathology*; D055815:Young Adult
Adenomegaly; Adénopathies; Cryptococcose; Cryptococcosis; Immunocompetence; Immunocompétence; Necrosis; Nécrose; Pneumonia; Pneumonie