《Table 2:Chest radiological findings of nonHIV adult patients with pulmonary cryptococcosis》

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《成年非HIV感染的肺隐球菌病患者血隐球菌抗原水平与肺部病变范围的相关性研究（英文）》

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HIV:Human immunodeficiency virus；CrAg:Cryptococcal antigen.

Cryptococcosis has been considered a disease of opportunistic infection，mainly，in immunocompromised patients with HIV/AIDS，cancers，and immunosuppressive treatment.[9，10]Moreover，C.neoformans was the predominant etiological agent of cryptococcosis.[11]It has been found that CD4+T?cell plays a critical role on immune responses to C.neoformans.[12，13]Th1 cytokines，such as interleukin（IL）?2，IL?12，interferon?γ，and tumor necrosis factor?α，orchestrate neutrophils and dendritic cells and activate macrophages to promote clearance of the pathogen.[14]Some studies figured out that cryptococcal meningoencephalitis is one of the most common disseminated fungal infections in HIV patients and the third most common invasive fungal infection in patients with organ transplants.[8，15，16]Otherwise，mountingevidence showed that the prevalence of cryptococcosis in immunocompetent hosts is increasing.[15，16]Then，pulmonary cryptococcosis is the leading type of cryptococcosis in non?HIV patients.[6，8，17]Baddley et al.found that，among166 HIV?negative patients with pulmonary cryptococcosis，122 had pulmonary infection only and 44 had pulmonary plus extrapulmonary infection.[17]Some studies showed that patients with pulmonary cryptococcosis were frequently symptomless or with mild symptoms.[6，8，9]Then，it is also wildly regarded that the diagnosis of pulmonary cryptococcosis is challenging.At present，serum CrAg screening has become a useful tool in cryptococcosis diagnosis.[18?20]High serum CrAg titer was considered to be associated with the load of fungi.[21]Meanwhile，serum CrAg also was used to monitor the recrudescence.[21]Nevertheless，we noticed that having negative serum CrAg is not rare among patients with pulmonary cryptococcosis，which was proven by biopsy later，in our clinical practices.Therefore，the characteristics of patients with and without serum CrAg test positive were worthy to be evaluated.In our study，114 patients with pulmonary cryptococcosis，proven by PTNB or postoperative biopsy，were screened and 85 patients were enrolled，56 in CrAg+group and 29 in CrAg-group.According to our results，we found that male（60.7%in CrAg+group and 55.2%in CrAg-group）was slightly more than female and cough and expectoration were two most common symptoms[Table 1].Interestingly，we also noticed that fever was rare in these patients，indicating that fever probably would be used as a symptom for exclusive diagnosis.Moreover，clubbing finger was not observed in our study，which is an important and typical sign of lung cancer，chronic tuberculosis，and other lung diseases.Kohno et al.also showed that only 3%（2 in 67）of non?HIV patients with pulmonary cryptococcosis had fever.[6]Since immunological status and underlying conditions are critical in fungal infection，the underlying status of patients was analyzed in our study.We found that only 17.9%in CrAg+group and 17.2%in CrAg-group were complicated with underlying diseases.Meanwhile，our data showed that T2DM and kidney transplantation were more common than other diseases[Table 1].In our study，laboratory findings，including Hb，PLT，WBC，neutrophils，and plasma PCT level，were analyzed.According to our data，no special change was observed between two groups，indicating that no severe systematical inflammatory response was stimulated in immunological systems.Moreover，these can partially explain the reason of symptomless or mild symptoms in pulmonary cryptococcosis.Therefore，further studies should be carried out to elucidate the underlying mechanism of the immune escape in pulmonary cryptococcosis.Then，these results suggested that pulmonary cryptococcosis showed untypical symptoms and laboratory findings，particularly without apparently infection features，in clinical practices.Moreover，most non?HIV adult patients with pulmonary cryptococcosis were not combined with underlying diseases.Therefore，we presumed that underlying diseases play a limited role in the pathogenesis of pulmonary cryptococcosis in non?HIV adult patients.