Disseminated blastomycosis and acquired immunodeficiency syndrome: a case report and ultrastructural study

Case study documenting the diagnosis of idiopathic CD4+ Lymphocytopenia in a patient with atypical fungal infection (disseminated blastomycosis) by FNA of adrenal mass

Idiopathic CD4+ lymphocytopenia, described in 1992 by the Centers for Disease Control, is characterized by persistent CD4+ lymphocytopenia (less than 300 cells per micro-liter) in nonimmunosuppressed, HIV negative individuals, who present with atypical infections. This rare though likely undiagnosed entity is associated with chronic disseminated forms of either fungal or bacterial infections in otherwise healthy adults. We report a case of a 59-year-old male with ring-enhancing brain lesions, bilateral adrenal masses, lung and vocal cord nodules, where the diagnosis of exclusion was metastatic malignancy. Fine needle aspiration (FNA) of the adrenal mass and a subsequent vocal cord biopsy confirmed chronic widely disseminated blastomycosis. Flow cytometric evaluation of peripheral blood documented persistent selective CD4+ lymphocytopenia with T8 (suppressor) T-Lymphocyte count within normal range. We believe that idiopathic CD4+ lymphocytopenia is an important etiologic factor to be considered for patients who present with mass lesions and are diagnosed by FNA with atypical fungal infections. We relate the diagnostic criteria for idiopathic CD4+ lymphocytopenia and the importance of providing on-site triage for FNA samples for fungal studies and correlation for flow cytometry.

Electron Microscopy Reveals Fungal Cells Within Tumor Tissue from Two African Patients with AIDS-associated Kaposi Sarcoma

Electron microscopic investigation of biopsy materials from Kaposi sarcoma (KS) skin lesions of 2 African AIDS patients occasionally revealed fungal cells within the tumor tissue. The spherical cells were surrounded by a triple-layered cell wall and were not encapsulated. The ultrastructural characteristics of the cells resemble those of Candida albicans organisms. Neither patient showed clinical signs of a generalized fungal infection. The presence of Candida albicans in the KS tissue specimens seems to represent an early and asymptomatic stage of cutaneous candidiasis in the 2 severely immunocompromised AIDS patients.

Blastomyces dermatitidis with large yeast forms

Yeast forms of Blastomyces dermatitidis typically range from 8 to 20 microm in largest diameter. We report a rare case of primary pulmonary blastomycosis with an unusual morphology, in which we found significant numbers of large yeast forms ranging from 30 to 35 microm in diameter. To our knowledge, this is only the second reported case of giant forms of B dermatitidis. We also review the literature and discuss the possible association of this unusual morphology with immunosuppression in general and glucocorticoid use in particular.