Primary cryptococcal infection of the larynx: report of a case

Cryptococcosis in the Vocal Cords, Trachea, and Bronchi

Laryngeal and endobronchial cryptococcosis are rare conditions, and to our knowledge, there have been only 23 cases of laryngeal cryptococcosis, and 18 cases of endobronchial cryptococcosis previously reported in the English literature. We herein report an extremely rare case of cryptococcosis with simultaneous laryngeal and endobronchial involvement. This case highlights the importance of paying close attention to possible occurrence of cryptococcosis of the airway tract in patients with asthma treated with high-dose inhaled corticosteroids.

Laryngeal Cryptococcosis Associated With Inhaled Corticosteroid Use: Case Reports and Literature Review

Laryngeal cryptococcosis is a rare clinical entity. There have been a limited number of case reports in the literature with no consensus regarding optimal management. This review contributes two additional case reports of immunocompetent patients with cryptococcal infection of the larynx in whom exposure to high doses of inhaled corticosteroids is proposed as a significant risk factor. Twenty cases were identified from review of the literature. All patients presented with hoarseness and a spectrum of microlaryngoscopic features, often mimicking laryngeal malignancy. The majority of cases were treated with systemic antifungal therapy, three cases had surgical excision alone, and another three had a combination of medical and surgical management. Risk factor modification, in the form of a reduction in inhaled corticosteroid was employed in the two new cases, and in some previously published cases. Risk factor modification, such as reduction of inhaled corticosteroid dose, in addition to oral antifungal agents can be effective in managing cryptococcal laryngitis.

Laryngeal cryptococcosis: Literature review and guidelines for laser ablation of fungal lesions

OBJECTIVES/HYPOTHESIS

To describe the demographics, clinical manifestations, diagnosis, treatment, and outcomes of laryngeal cryptococcosis. Antifungal therapy guidelines are provided and the use of laser ablation is discussed.

DATA SOURCES

PubMed, OVID MEDLINE, and Embase databases and one patient who presented to our institution's otolaryngology department.

REVIEW METHODS

A review of the English-language international medical literature was conducted using the terms ("larynx" or "laryngeal diseases") and ("Cryptococcus" or "cryptococcosis") to identify reported cases of laryngeal cryptococcosis. Databases were searched from inception through January 2015.

RESULTS

Eighteen cases were identified and reviewed, including the first reported case of potassium-titanyl-phosphate laser ablation. All patients presented with hoarseness, and two (11%) presented with acute airway obstruction that required tracheotomy. Six patients (33%) were immunocompromised, including three (17%) who had an underlying human immunodeficiency virus infection. Seven cases (39%) described an exophytic mass. Histopathology indicated pseudoepitheliomatous hyperplasia in seven of the 17 reported results (41%). Methenamine silver stain was used in 12 of the 15 described cases (80%) to identify the fungus. Lumbar puncture results were reported for seven patients, none of whom had meningitis. Antifungal therapy was used in 15 cases (83%), and two (11%) received additional laser ablation treatment. Eleven patients (61%) had complete resolution.

CONCLUSIONS

Laryngeal cryptococcosis is a rare cause of persistent hoarseness. Most patients have complete resolution after treatment. For complex and obstructive cases, laser ablation coupled with antifungal therapy can successfully manage laryngeal cryptococcosis in select patients.

LEVEL OF EVIDENCE

NA Laryngoscope, 126:1625-1629, 2016.

Primary Larynx Cryptococcus neoformans Infection: A Distinctive Clinical Entity

Cryptococcus neoformans can directly infect the vocal cords. Endoscopic findings were undistinctive from most infiltrative diseases. Tissue biopsy was essential for the diagnosis. Inhaled corticosteroids can predispose to the infection, and fluconazole 400 mg daily for at least 6 weeks appeared to be minimal to achieve a permanent cure.

Primary laryngeal cryptococcosis resembling laryngeal carcinoma

A case of an 82-year-old female with primary laryngeal cryptococcosis who had undergone long-term corticosteroid therapy for chronic obstructive pulmonary disease and rheumatoid arthritis is reported. She complained hoarseness with swallowing pain and irritability of the larynx for over a month. Endoscopic examination revealed a white, exudative irregular region on right arytenoid that mimicked a laryngeal carcinoma. Histological examination showed pseudoepitheliomatous hyperplasia and severe submucosal inflammation with ovoid budding yeasts by Grocott's stain. A serological study indicated a high titer of cryptococcal antigen. After treating with oral fluconazole for 3 months, her primary lesion of larynx turned to be clear. We implicate a long-term use of steroids as the significant risk factor in developing cryptococcosis of the larynx.

[Mycoses of the head and neck]

OBJECTIVES

The ever growing number of immunocompromized patients and increasing travel to areas where fungal diseases are endemic explain why in recent years mycoses have emerged as important infections in clinical practice. It is essential that pathologists and clinicians be knowledgeable about them.

RESULTS

Head and neck infections are common in disseminated mycoses. The most frequent causative yeasts or yeast-like organisms include Candida albicans, Cryptococcus neoformans, Histoplasma capsulatum var capsulatum, Blastomyces dermatitidis, Paracoccidioides brasiliensis and Coccidioides immitis. Other causative fungal pathogens include Aspergillus fumigatus and less frequently, Rhizopus oryzae and Rhinosporidium seeberi. Since their pathophysiology is in most cases similar, those microorganisms share a common clinical pathological picture. Head and neck mycoses may simulate carcinoma or cause upper airway obstruction. Symptoms such as dysphonia or dysphagia associated with hyperplastic and ulcerative lesions on endoscopic examination should prompt biopsies. An inflammatory tissue reaction with pseudoepitheliomatous hyperplasia warrants caution since it may lead to a mistaken diagnosis of cancer.

CONCLUSION

The pathologist must look carefully for microorganisms with special stains. Clinicians and pathologists must be aware of these mycoses to identify the causative agent, isolated it by culture, and prescribe adequate treatment for the patients.

Les mycoses ORL

In recent years, mycoses have emerged as important infections in clinical practice. This phenomenon is explained by the ever growing number of immunocompromised patients and the increasing number of people travelling in areas where fungal diseases are endemic. Head and neck infections are common in disseminated mycoses and may simulate carcinoma or cause upper airway obstruction. The most frequent causative yeasts or yeast-like organisms include Candida albicans, Cryptococcus neoformans, Histoplasma capsulatum var capsulatum, Blastomyces dermatitidis, Paracoccidioides brasiliensis and Coccidioides immitis. Other causative fungal pathogens include Aspergillus fumigatus and less frequently, Rhizopus oryzae and Rhinosporidium seeberi. Since in most cases their pathophysiology is similar, those microorganisms share a common clinical pathological presentation. Symptoms such as dysphonia or dysphagia associated with hyperplastic and ulcerative lesions on endoscopic examination should prompt biopsies. A purulent or granulomatous inflammatory tissue reaction with pseudoepitheliomatous hyperplasia warrants caution since it may lead to a mistaken diagnosis of carcinoma. The pathologist must look carefully for microorganisms with Grocott and PAS stains. The causative agent can be identified if the pathologist is aware of the risk. Positive culture is needed to institute adequate treatment.