Our patient was a 65-year-old Korean woman with 3-year history of RA, which had been treated with methotrexate (10 mg/wk), leflunomide (20 mg/day), and triamcinolone (0.5 mg/day). She had a 2-year history of known diabetes, which had been well controlled with metformin (500 mg) once daily. Additionally she had been taking anti-hypertensive drugs, (amlodipine 5 mg and losartan 50 mg) once daily for 5 years. She had no history of smoking and alcohol abuse. She had a mild cough, weight loss of 5 kg during the last 6 months (body mass index [BMI], 21.6 kg/m
2). At her first visit to our clinic, she did not look very ill; her vital signs were stable. She had four rheumatoid nodules in both hands. Auscultation of the right lower lung field revealed crackle. Laboratory test results showed the following: white blood cell (WBC), 5,800/µL; red blood cell (RBC), 10.5 g/dL; haematocrit (Hct), 29.6%; platelet, 256,000/µL; segmented neutrophil, 71.4%; lymphocyte, 16%; monocyte, 10.7%; eosinophil, 1.3%; and basophil, 0.6%; high-sensitivity C-reactive protein, 2.1 mg/L; erythrocyte sedimentation rate (ESR), 21 mm/hr; rheumatoid factor (RF), <20 IU/mL; and haemoglobin A1c, 5.5%. Serum electrolyte, liver, and renal function test results were normal; serum
Aspergillus antigen, sputum acid-fast bacilli (AFB) smear and culture test results were negative. The CXR and chest computed tomography (CT) scans demonstrated irregularly shaped two cavitary nodules sized 2.5×2.3×2 cm and 1×1×0.8 cm, respectively, in the right lower lung lobe (
Figure 1A). The lesion continued to gradually grow in size during the last 6 months before admission. Diagnostic bronchoscopy revealed no endobronchial lesion; the bronchial washing specimen from the right lower lobe showed no evidence of pulmonary tuberculosis or malignancy. The mass was surgically resected by wedge resection via video-associated thoracoscopy because the tissue from the initial percutaneous needle biopsy was non-diagnostic, and malignancy or other infectious diseases were suspected and had to be ruled out. Surgical biopsy confirmed the rheumatoid nodule from an area of necrotising granulomatous inflammation, with a negative AFB smear or culture result (
Figure 2). The RA therapy was maintained with the same regimen, and she was clinically stable for 18 months. However, she presented with general weakness, anorexia, and an additional weight loss of 3 kg in the past 3 months (BMI, 19.34 kg/m
2). She took herb medication for diabetes control during the 3-month period. However, newly growing huge opacity with cavitation in the same location and additional multiple nodules were detected on CXR (
Figure 1C). Laboratory tests revealed the following: WBC, 11,800/µL; RBC, 10.2 g/dL; Hct, 31%; platelet, 466,000/µL; segmented neutrophil, 81%; lymphocyte, 10%; monocyte, 3%; eosinophil, 3%; basophil, 1%; high-sensitivity C-reactive protein, 18.9 mg/L; ESR, 120 mm/hr; RF, 34.5 IU/mL; and haemoglobin A1c, 5.0%. Bronchoscopic findings showed a negative
Aspergillus antigen titre and negative AFB smear and culture results. CT-guided transthoracic needle biopsy was performed to determine other causes of infection or malignancy. Pathologic findings were compatible with pulmonary cryptococcosis (
Figure 2).
Cryptococcus antigen was found in serum but not in cerebrospinal fluid. The
Cryptococcus antigen titre could not be measured. Cerebrospinal fluid analysis result was within the reference range. She was treated with oral fluconazole (400 mg) once daily. Four months later, she became well without any symptoms. Follow-up imaging studies showed improvement of the previously noted lesion (
Figure 1D).