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The Diagnostic Challenge of an Infrequent Spectrum of Cryptococcus Infection. Case Rep Radiol 2019; 2019:5970648. [PMID: 30719369 PMCID: PMC6334315 DOI: 10.1155/2019/5970648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 12/23/2018] [Indexed: 01/07/2023] Open
Abstract
Cryptococcal infection results from inhalation of fungal spores and usually is confined to the lungs, but may disseminate systemically. Radiologically, cryptococcal infection has multiple forms of presentation. The diagnosis is usually based on fungal isolation from cultured clinical specimens. Long term antifungal therapy is recommended, but surgical procedures may eventually be necessary when large thoracic symptomatic masses are present. We report a case of a 41-year-old male, immunocompetent, investigating a palpable mass in the left supraclavicular region associated with unintentional weight loss over the last three months. He also reported chest pain in this period. Chest X-ray, ultrasonography, and computed tomography were performed, which diagnosed a mediastinal and left supraclavicular mass, interpreted as lymph node conglomerates of unknown etiology. He also underwent a biopsy of the left supraclavicular mass for etiological determination by histopathology, which confirmed cryptococcosis infection. Although very infrequent, mediastinal cryptococcal infection (simulating masses) is a challenging but important differential diagnosis of benign and malignant lesions, since its treatment is usually clinical.
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Chichra A, Lama KW, Koenig SJ. Respiratory failure with hilar mass: Role of endobronchial ultrasound-guided transbronchial needle aspiration in the medical intensive care unit. Lung India 2015; 32:178-81. [PMID: 25814808 PMCID: PMC4372877 DOI: 10.4103/0970-2113.152647] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
We report the case of a 58-year-old man on chronic steroid therapy, who developed a rapidly progressive right upper lobe infiltrate/mass that extended into the right hilum. Respiratory failure necessitated endotracheal intubation. Broad spectrum antibiotics were initiated without clinical improvement and because of his immunosuppressive therapy opportunistic pathogens were considered. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was performed in the Medical Intensive Care Unit (MICU) with rapid onsite evaluation. Specimens obtained from the right hilar mass revealed organisms suspicious for cryptococcal infection, subsequently confirmed via a culture. No complications occurred during the EBUS procedure despite the patient requiring vasopressor support and 100% inspired oxygen. Little data exists regarding the use of EBUS in patients admitted to the MICU with respiratory failure of unknown etiology and mediastinal/hilar lymphadenopathy. This case illustrates the potential safe use of EBUS-TBNA in patients presenting with respiratory failure, with a mediastinal or hilar mass and suspected infectious etiology.
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Affiliation(s)
- Astha Chichra
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Hofstra North Shore - Long Island Jewish Health System, New York, United States
| | - Kimmoi Wong Lama
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Hofstra North Shore - Long Island Jewish Health System, New York, United States
| | - Seth J Koenig
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Hofstra North Shore - Long Island Jewish Health System, New York, United States
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Dharwadkar A, Vimal S, Buch AC, Panicker NK. HIV infection presenting as bone marrow cryptococcosis. Adv Biomed Res 2014; 3:144. [PMID: 25161991 PMCID: PMC4139979 DOI: 10.4103/2277-9175.135161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Accepted: 02/03/2013] [Indexed: 11/04/2022] Open
Abstract
Disseminated cryptococcal infection is an uncommon initial manifestation in immunocompromised patients. We report a rare case of a 40-year-old female presenting with fever and burning epigastrium. Peripheral blood film revealed a leukoerythroblastic picture with thrombocytopenia. Bone marrow aspiration showed granulomas along with cryptococcal yeast forms. The ELISA test for detection of human immunodeficiency virus (HIV) antigen was positive. Disseminated cryptococcosis can develop as the first manifestation of HIV infection in previously healthy individuals and granulomas in such bone marrow aspiration smears are a valuable clue to an underlying opportunistic infection.
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Affiliation(s)
- Arpana Dharwadkar
- Department of Pathology, Pad Dr DY Patil Medical College, Pune, Maharashtra, India
| | - Shruti Vimal
- Department of Pathology, Pad Dr DY Patil Medical College, Pune, Maharashtra, India
| | - Archana C Buch
- Department of Pathology, Pad Dr DY Patil Medical College, Pune, Maharashtra, India
| | - N K Panicker
- Department of Pathology, Pad Dr DY Patil Medical College, Pune, Maharashtra, India
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Abstract
We describe a case of a 35-year-old man with human immunodeficiency virus infection/acquired immune deficiency syndrome presenting from an outside hospital with a diagnosis of non-Hodgkin's B-cell lymphoma. Radiologic imaging showed an infiltrative process with significant tracheal involvement and increased uptake of 18-fluoro-2-deoxyglucose on positron emission tomography. These findings were suspicious for non-Hodgkin's B-cell lymphoma. Flexible bronchoscopy and tissue sampling revealed cryptococcal infection of the trachea. This case presentation is of extensive cryptococcal tracheitis, an extremely rare presentation of endobronchial cryptococcosis. It also emphasizes the difficult radiologic distinction between such unusual endobronchial infections and malignancy.
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Wong M, Loong F, Khong PL, Kwong YL, Leung AYH. Mediastinal cryptococcosis masquerading as therapy-refractory lymphoma. Ann Hematol 2010; 90:601-2. [PMID: 20730538 PMCID: PMC3070883 DOI: 10.1007/s00277-010-1054-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 08/08/2010] [Indexed: 11/25/2022]
Affiliation(s)
- Matthew Wong
- Department of Medicine, Queen Mary Hospital, Pokfulam Road, Hong Kong, China
| | - Florence Loong
- Department of Pathology, Queen Mary Hospital, Pokfulam Road, Hong Kong, China
| | - Pek-Lan Khong
- Department of Diagnostic Radiology, Queen Mary Hospital, Pokfulam Road, Hong Kong, China
| | - Yok-Lam Kwong
- Department of Medicine, Queen Mary Hospital, Pokfulam Road, Hong Kong, China
| | - Anskar Y. H. Leung
- Department of Medicine, Queen Mary Hospital, Pokfulam Road, Hong Kong, China
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Atypical Micromorphology and Uncommon Location of Cryptococcosis: A Histopathologic Study Using Special Histochemical Techniques (One Case Report). Mycopathologia 2008; 167:197-202. [DOI: 10.1007/s11046-008-9169-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Accepted: 11/06/2008] [Indexed: 11/27/2022]
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Pantanowitz L, Omar T, Sonnendecker H, Karstaedt AS. Bone marrow cryptococcal infection in the acquired immunodeficiency syndrome. J Infect 2000; 41:92-4. [PMID: 11041711 DOI: 10.1053/jinf.2000.0667] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To describe the bone marrow lesions in eight cases of Cryptococcus neoformans infection involving the bone marrow in HIV-infected patients. METHODS Archival bone marrow biopsies from patients with HIV-related cryptococcosis of the bone marrow were retrospectively reviewed. Cryptocococcal organisms were identified on haematoxylin- and eosin-stained slides and confirmed using mucicarmine staining. RESULTS Yeast cells stimulated a granulomatous response in all cases despite immunosuppression. The number of cryptococcal organisms appeared to be inversely proportional to the adequacy of the granulomatous response. All patients had a cytopenia. CONCLUSIONS The ability to mount a tissue response in order to localize organisms is retained in patients with AIDS. Infection of the bone marrow with cryptococci may act in synergy with HIV to cause cytopenia.
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Affiliation(s)
- L Pantanowitz
- Department of Medicine, Chris Hani Baragwanath Hospital and South African Institute for Medical Research, University of Witwatersrand, Johannesburg, South Africa
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Minamoto GY, Rosenberg AS. Fungal infections in patients with acquired immunodeficiency syndrome. Med Clin North Am 1997; 81:381-409. [PMID: 9093234 DOI: 10.1016/s0025-7125(05)70523-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The incidence and severity of fungal infections appear to increase with progression of HIV disease. Because of the significant morbidity and mortality associated with the mycoses discussed, knowledge of the clinical syndromes, early diagnosis, and prompt institution of therapy are crucial for a favorable outcome. For disseminated or invasive fungal infections, suppressive therapy must be continued to prevent relapse.
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Affiliation(s)
- G Y Minamoto
- Department of Clinical Medicine, Columbia University, New York, New York, USA
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Mitchell TG, Perfect JR. Cryptococcosis in the era of AIDS--100 years after the discovery of Cryptococcus neoformans. Clin Microbiol Rev 1995; 8:515-48. [PMID: 8665468 PMCID: PMC172874 DOI: 10.1128/cmr.8.4.515] [Citation(s) in RCA: 801] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Although Cryptococcus neoformans and cryptococcosis have existed for several millennia, a century has passed since the discovery of this encapsulated yeast and its devastating disease. With the advent of the AIDS pandemic, cryptococcal meningitis has emerged as a leading cause of infectious morbidity and mortality and a frequently life-threatening opportunistic mycosis among patients with AIDS. Both basic and clinical research have accelerated in the 1990s, and this review attempts to highlight some of these advances. The discussion covers recent findings, current concepts, controversies, and unresolved issues related to the ecology and genetics of C. neoformans; the surface structure of the yeast; and the mechanisms of host defense. Regarding cell-mediated immunity, CD4+ T cells are crucial for successful resistance, but CD8+ T cells may also participate significantly in the cytokine-mediated activation of anticryptococcal effector cells. In addition to cell-mediated immunity, monoclonal antibodies to the major capsular polysaccharide, the glucuronoxylomannan, offer some protection in murine models of cryptococcosis. Clinical concepts are presented that relate to the distinctive features of cryptococcosis in patients with AIDS and the diagnosis, treatment, and prevention of cryptococcosis in AIDS patients.
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Affiliation(s)
- T G Mitchell
- Department of Microbiology, Duke University Medical Center, Durham, North Carolina 27710, USA
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Wong KF, Ma SK, Chan JK, Lam KW. Acquired immunodeficiency syndrome presenting as marrow cryptococcosis. Am J Hematol 1993; 42:392-4. [PMID: 8493992 DOI: 10.1002/ajh.2830420412] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Disseminated cryptococcal infection is an uncommon initial manifestation in patients with the acquired immunodeficiency syndrome. The most common sites of involvement by cryptococci are the central nervous system and the lungs, and involvement of the marrow is rare. There are few descriptions in the literature on the cytologic findings of marrow cryptococcosis. We report a patient with disseminated cryptococcosis in which cytologic examination of the marrow provides the first clue to the diagnosis.
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Affiliation(s)
- K F Wong
- Institute of Pathology, Queen Elizabeth Hospital, Kowloon, Hong Kong
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Abstract
The rapid and thus far generally inexorable rise in HIV infections has led to a series of opportunistic infection that includes those caused by bacteria, yeasts, and members of the Eumycetes. The infections range in prevalence from occasional to highly prevalent, in severity from trivial to fatal, and in anatomic areas involved from local to disseminated. They occur as isolated, concurrent, or sequential infections with regard to other opportunistic diseases. Some vary in their geographic distribution. They may be newly acquired or reactivated and occur early or late in the course of HIV infection. Bacterial infections are usually easily treated, although they frequently disseminate and often recur after seemingly appropriate treatment. In contrast, all but the mildest fungal infections are difficult to treat and even more difficult or impossible to eradicate. The diagnosis of bacterial and fungal infections begins with clinical suspicion and involves relatively standard methodology. Treatment of the systemic mycoses and some bacterial infections in HIV infected patients is punctuated by exaggerated side effects of therapy, frequent relapses, and the need for maintenance suppressive therapy.
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Affiliation(s)
- E S Daar
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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Cohen PR, Held JL, Grossman ME, Ross MJ, Silvers DN. Disseminated histoplasmosis presenting as an ulcerated verrucous plaque in a human immunodeficiency virus-infected man. Report of a case possibly involving human-to-human transmission of histoplasmosis. Int J Dermatol 1991; 30:104-8. [PMID: 2001898 DOI: 10.1111/j.1365-4362.1991.tb04220.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A 46-year-old homosexual man with disseminated histoplasmosis and human immunodeficiency virus (HIV) infection had a histoplasmosis-related ulcerated verrucous plaque above his left upper lip; systemic and cutaneous disease manifestations of histoplasmosis resolved with daily ketoconazole therapy. Disseminated histoplasmosis, with similar cutaneous features, also was present in his HIV-seropositive male sexual partner. The possibility of human-to-human transmission of histoplasmosis between these patients is considered and the skin lesions of systemic fungal infections in HIV-infected patients are reviewed.
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Affiliation(s)
- P R Cohen
- Department of Dermatology, College of Physicians and Surgeons of Columbia University, New York, New York
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 37-1990. A 28-year-old man with increasing dyspnea, dry cough, and fever after chemotherapy for lymphoma. N Engl J Med 1990; 323:737-47. [PMID: 2388671 DOI: 10.1056/nejm199009133231108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
Cryptococcus neoformans has become an increasingly important pathogen. Cryptococcosis is an important cause of morbidity and mortality in immunocompromised hosts and is the second most common fungal infection complicating AIDS. In recent years, research has focused on the host defenses against Cryptococcus and has led to an improved understanding of the capsular virulence of the organism, the mechanisms of T-cell defenses, and the role of phagocytic cells in the fungistasis and killing of cryptocci. Amphotericin B with or without flucytosine has clearly improved treatment of cryptococcosis, but therapy is associated with significant toxicity. Current investigation is focused on the triazoles, which may offer improved therapy for cryptococcosis. In this report, we review recent developments in the understanding of the host defenses against Cryptococcocus and discuss current recommendations for the management of cryptococcosis.
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Affiliation(s)
- T F Patterson
- Yale University School of Medicine, Department of Medicine, New Haven, Connecticut 06510
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Scalfano FP, Prichard JG, Lamki N, Athey PA, Graves RC. Abdominal cryptococcoma in AIDS: a case report. THE JOURNAL OF COMPUTED TOMOGRAPHY 1988; 12:237-9. [PMID: 3048904 DOI: 10.1016/0149-936x(88)90017-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Cryptococcosis is a recognized opportunistic pathogen in the acquired immune deficiency syndrome. Although central nervous system infection and disseminated cryptococcosis is common in acquired immune deficiency syndrome, localized infection is rare. We present a case of massive retroperitoneal and mesenteric adenopathy in a male homosexual patient with acquired immune deficiency syndrome with clinical and radiologic features suggestive of lymphoma. However, this was proven pathologically to represent cryptococcal infiltration of the lymph nodes. Our experience indicates that Cryptococcus neoformans should be included in the differential diagnosis of massive abdominal adenopathy in the acquired immune deficiency syndrome.
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Affiliation(s)
- F P Scalfano
- Department of Radiology, Baylor College of Medicine, Houston, Texas 77030
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Gold JE, Jimenez E, Zalusky R. Human immunodeficiency virus-related lymphoreticular malignancies and peripheral neurologic disease. A report of four cases. Cancer 1988; 61:2318-24. [PMID: 3365659 DOI: 10.1002/1097-0142(19880601)61:11<2318::aid-cncr2820611129>3.0.co;2-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The most common human immunodeficiency virus-related (HIV) malignancies to date include Kaposi's sarcoma and the high-grade non-Hodgkin's lymphomas. There also appears to be an association between HIV and an aggressive form of Hodgkin's disease. In addition, there is a spectrum of HIV-related central and peripheral neurologic syndromes. This article documents four patients with HIV-associated lymphoma who presented with peripheral neurologic syndromes as part of their neoplastic process. Autopsy results obtained from two of these patients showed direct nerve infiltration by lymphoma. All patients had an elevated serum lactate dehydrogenase (LDH). It is recommended that HIV-related lymphoma be considered in a high-risk patient who presents with a peripheral neurologic syndrome especially if there is an elevated serum LDH.
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Affiliation(s)
- J E Gold
- Department of Medicine, Beth Israel Medical Center, Mount Sinai School of Medicine, City University of New York, New York 10003
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Murray RJ, Becker P, Furth P, Criner GJ. Recovery from cryptococcemia and the adult respiratory distress syndrome in the acquired immunodeficiency syndrome. Chest 1988; 93:1304-6. [PMID: 3163539 DOI: 10.1378/chest.93.6.1304] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
We describe a patient who presented with cryptococcosis and the adult respiratory distress syndrome (ARDS) as the initial manifestation of the acquired immunodeficiency syndrome. This patient represents the first reported recovery from ARDS secondary to widespread cryptococcosis. He is currently doing well as an outpatient on maintenance therapy with amphotericin B and azidothymidine.
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Affiliation(s)
- R J Murray
- Department of Medicine, University of Maryland School of Medicine, Baltimore 21201
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