We report a case of a 41-year-old male, immunocompetent, with no other comorbidities who went to the hospital to investigate unintentional weight loss in the last three months and to investigate a hard and palpable mass in the left supraclavicular region. He underwent series of laboratory tests and several imaging tests, such as blood cells count, T-cells immunophenotypes, analysis of B and NK-cells, and expression of interferon gamma receptor searching for immunodeficiencies:all in the normal range: neutrophils 5,72 mil/mm3 (reference titles 4,00 -11,00 mil/mm3), lymphocytes 3,69 mil/mm3 (reference titles 1,60 - 7,00 mil/mm3), monocytes 0,55 mil/mm3 (reference titles  and eosinophils 0,07 mil/mm3 (reference titles 0,05 - 0,50 mil/mm3); inflammatories parameters like C-reactive protein 151,1 mg/L (reference titles < 5,0 mg/L) were elevated; and inflammatories parameters like DHL 191 mg/L (reference titles 135-225 mg/L) were normal. Cryptococcal capsular antigen dosages were made in the blood and spinal fluid, giving positive results (reagents) with a titre of 1:32. Viral serologies like HIV, hepatitis, and HTLV were all negative; acid-alcohol resistant bacillus (BAAR) spur was negative.
He also performed same imaging studies such as chest X-ray (Figure 1), chest computed tomography (Figures 2, 3, and 4), and ultrasonography (Figure 5), which demonstrate mediastinal and left supraclavicular masses, interpreted as lymph node conglomerates of unknown etiology. Therefore the main diagnostics hypothesis was lymphoproliferative or granulomatous infectious diseases, especially tuberculosis.
He underwent a fine needle aspiration (Figure 5) of the left supraclavicular mass. Histopathology (Figures 6 and 7) showed a granulomatous inflammation with fungal identification, and immunohistochemistry was positive for Grocott-methenamine silver nitrate and mucicarmine (Figures 6 and 7). The final diagnostic was Cryptococcus neoformans var. gattii. Ziehl-Neelsen coloration was negative (Figures 6 and 7).
He was first treated clinically, with intravenous antifungal therapy for almost 60 days (6 days of fluconazol being replaced with 57 days of flucytosine and 59 days of B-amphotericin lipidic complex), but he did not improve, with remaining pulmonary symptoms.
Therefore, a multidisciplinary team decided for surgical resection. The lesion was almost entirely resected (Figures 8 and 9). Histopathology and cultures confirmed the lesion as cryptococcoma.
The patient was being followed clinically and radiologically (Figure 9) and had no symptoms or complications so far.