Faisal, S

Kapadia, N

Memon, A M

Memon, S B

Soomro, I N

English

eCommons@AKU

eCommons@AKUSection of Internal Medicine Department of MedicineSeptember 2001Cryptococcus--diversity of clinical presentationS B. MemonAga Khan UniversityA M. MemonAga Khan UniversityS FaisalAga Khan UniversityN KapadiaAga Khan UniversityI N. SoomroAga Khan UniversityFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_med_intern_medRecommended CitationMemon, S. B., Memon, A. M., Faisal, S., Kapadia, N., Soomro, I. N. (2001). Cryptococcus--diversity of clinical presentation. Journal ofPakistan Medical Association, 51(9), 337-339.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_med_intern_med/57Cryptococcus - Diversity of Clinical PresentationS. B. Memon ( Final year Medical Student, The Aga Khan University, Karachi. ) A. M. Memon,S. Faisal ( Deparments of Medicine, The Aga Khan University, Karachi. ) N. Kapadia ( Deparments of Dermatology, The Aga Khan University, Karachi. ) I. N. Soomro ( Deparments of Pathology, The Aga Khan University, Karachi. ) Introduction Cryptococcus neoformans is encapsulated yeast, which is highly prevalent in the soil. animals and as acolonist in humans1. The most important event involved in host defense against Cryptococcusneoformans is the development of an adequate cell-mediated immune response2 particularly T cellmediated immunity3. The level of immunity caq cause the spectrum to vary from mere colonization ofthe respiratory tract to serious meningitic or disseminated forms of illness4. However, humancryptococcal disease is generally encountered in patients with leukemia. Hodgkin’s disease or non-Hodgkin’s lymphoma, in those receiving prolonged steroid therapy, or in people who have AcquiredImmunodeflciency Syndrome. Although the immune status is an important factor in determining thedegree of infection. reports have shown that 50% of patients do not have any recognizable antecedentor concomitant immunodefic iency5,6.We came across two unusual cases. In the first case marked eosinophilia was noted. The second patienthad cryptococcal infection in the breast.Case Report Case 1A 16-year-old female student presented with a history of pyrexia and cough for eight months. The feverwas low grade, occurred in the evenings and was not associated with rigors. She occasionally producedyellow sputum. There was no history of dyspnea.Auscultation revealed coarse crackles bilaterally. Her chest X-ray showed diffuse bilateral interstitialinfiltrates with honey comb pattern. An ultrasound of the abdomen showed hepatosplenomegak. Herhemoglobin level was 9.8 gm/dl, total leukocyte count was 21,000 and the peripheral blood smearshowed 50% eosinophils, 27% neutrophils and 21% lymphocytes. A bone marrow aspirate and trephinerevealed normal hemopoietic precursor cells, erythropoiesis was normoblastic and myelopoiesisshowed increase in the eosinophilic precursors which comprised about 40-45% of the total nucleatedcells in the bone marrow. No evidence of parasitic infection was found on stool examination. Empiricaltreatment with mebendazol for three days did not result in any improvement in eosinophilia. Hersputum AFB smear was negative. ANA, ASMA and AMA were negative .On the basis of her clinicalpresentation she was started on anti tuberculosis therapy. Her condition worsened over the next monthwith her temperature increasing to 101-1020 F and she developed hemoptvsis. She had also developedan acneform, umblicated pustular rash on her face similar to Molluscum contagiosum (Figure 1).A screening test for human irnmunodeflciency virus antibodies by enzyme-linked immunosorbentassay was negative. During hospitalization her left cervical lymph node became enlarged. Discrete 1-2cms diameter firm, non tender lymph nodes were palpable below the angle of the left mandible. Thehistopathological examination of one of these lymph nodes revealed chronic granulomatous reactioncomposed of macrophages, lymphocytes and foreign body giant cells. Small cystic space filled withnumerous cyptococci were seen. The entire tissue was studded with Cryptococcus neoformans (Figure2).She was started on amphotericin and was discharged in improved status.Case 2A 45-year-old diabetic housewife presented with fever, history of weight loss and enlargingsubcutaneous masses over various parts of her body since the past six months. These masses were ofvarying size and the largest swelling was present in the upper outer quadrant of the left breast. Thislump was firm, well defined, non- tender and about 3 cm in diameter. The overlying skin was normal.There was no discharge from her nipple. This lump was associated with a soil left axillary lymph nodeabout 5 cm in diameter. Due to this firm breast mass and associated subcutaneous nodular eruptions,carcinoma of the breast with metastasis was suspected. A mammograph could not he done because offinancial constraints and paucity of facilities. A fine needle biopsy of this lump and of another lump inthe thigh was performed. Cryptococci were seen with collections of histiocytes and multinucleatedgiant cells. Presence of typical periodic acid- Schiff yeasts led to the diagnosis of cryptoccocalinfection.Treatment with Intravenous Amphotercin for initial two weeks resulted in significant reduction in sizeof the swellings. Subsequently she was switched to Fluconazole 400 mg, which was administered foreleven weeks. All of her masses disappeared except a scarred single left axillary lymph node. Followup over last three years has not shown any sign of relapse.Discussion The presentation in both of these cases was distinctive. The unique facet of the first case was thatcryptococcal disease and eosinophilia were a consistent finding. The serial absolute eosinophil countwas above 1.5x109/liter which qualified this case as hypereosinophilia7. Eosinophilia to this extent isusually found in parasitic infections, allergic disorders, vasculitides and lymphoreticular malignancies8.Fungal infections in which peripheral eosinophilia has been documented are coccidioidomycosis,especially in disseminated infection9 and in allergic bronchopulmonary aspergillosis10. The apartmentbuilding where the first patient grew up was at one time inhabited with wild pigeons. A visit to herhouse by one of the authors with a team of physicians and a microbiologist did not reveal any source offungal growth. Cultures taken from the soil of the dormitory where she had been staying for previoustwo years also did not show any Cryptococc i. Cry ptococcal infection is usually associated with aslight neutrophilic leukocytosis in the peripheral blood and chronic meningitis in the CSF11. This caseas well as others written in the same context revises the need to include cryptococcal infection in thedifferential diagnosis of peripheral eosinophilia.In the second case the patient presented with a breast lesion. The most common fungal infection of thebreast is Candida albicans, which usually occurs in women after childbirth12,13. Cryptococcal infectionof the breast is a rare but treatable condition that may occur in both normal and immunocompromisedhosts and may mimic other more common forms of breast disease, including carcinoma of the breast14In this case we suspected carcinoma of the breast and performed a fine needle biopsy that proved to bediagnostic. The rote for surgery alone is questionable and it is advised that surgery should be combinedwith systemic antifungal even if there is no documented infection outside the breast14.We conclude that presence of eosinophilia should not distract us from considering Cryptococcus in thedifferential diagnosis. This fungus should be included in list of causes of breast lump.References 1.Perfect JR. Durack DT. Gallis HA Crviococcemia. Medidine 1983:62:98:109.2.Monari C. Retim C, Palazzetti B, Bistoni F. Vecchiarelli A. Regulatory role of exogenous IL-10 in thedevelopment of immune response versus Crviococcus neoformans, Clin. Exp. immunol.,1997:109:242-7.3.Mody CH, Lipscotnb ME. Street NE. Toews GB. Depletion of CD4+ (L3T4+) lymphocytes in vivoyimpairs murine host defense to Cryptococcus neoformans. J lmmunol., 1990:144 472-7.4.Leggaiadro RJ. Barrett FF. Hughes WT. Lxtrapulmonarv crytococcus in immunocompromised infantsand children. Pediatr. Infect. Dis, J., 1992:11:43-7.5.Emmanual 3. Ching E, Lieberman AD. Goldin M Crytococcus meningitis in a child successfullytreated with Amphotericin-B with a review of the pediatnc literature. J Pediatr., 1961:59:577-91.6.Stewers CMF, Cramblett HG. Crytococcosis (torulosis) in children. Pediatrics.. 1964:34:393-400.7.Spry CJF. The hypereosinophilic syndrome: clinical features. laboratory findings and treatmentAllergy.. 1982:37:539-51.8.Shurin SB. Pathologic states associated with activation of eosinophils and with eosinophilia Hematol,Oncol. Clin. North. Am., 1988:2.171-9.9.Weller PF. Eosinophilic meningitis. Am. J. Med.. 1993;95:250-3.10.Scherinoly Mi. Hinthom DR. Eosinophilia in coccidioidomycosis. Arch. Intern. Med. 988,148:895-6.11.Marwaha RK. Trehan A. iayashree K, Vasishta RK Hy pereosmophilia in disseminated crytococcaldisease. Pediatr. Infect. Dis.J., 1995:14:1102-3.12.Goldman M, Pottage JC. Crvtococcal Infection of the Breast. Clinical. Infectious. Diseases..1995:21:1166-9.13.Opri F. Mammary mvcoses. Chemotherapy. I 982.28(sttppl 1 ).6 1-5.14.Amir LH. Candida arid the lactating breast: predisposing factors J. Human Lactation.. 1991:7:177-81.

Cryptococcus--diversity of clinical presentation

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Cryptococcus--diversity of clinical presentation

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