Cryptococcus peritonitis a rare manifestation in HIV positive host: A case report
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Transcript of Cryptococcus peritonitis a rare manifestation in HIV positive host: A case report
Cryptococcus Peritonitis aRare Manifestation in HIVPositive Host:A Case ReportPuja Singh, M.D., Deepti Joshi, M.D., and Nitin Gangane, M.D., D.N.B.*
Cryptococcus neoformans is an encapsulated yeast found ubiqui-tously in the environment and causes serious infections in immu-nocompromised populations. Disseminated disease is uncommonand very rarely manifests as peritonitis. We report a case ofcryptococcal peritonitis in a HIV positive patient, who presentedwith distention of abdomen, vomiting, and dyspnoea, where thediagnosis was made on cytological smears of ascitic fluid. Theimportance of making a quick diagnosis utilizing cytologicalsmears is emphasized and the cytological features are demon-strated. Disseminated cryptococcosis, particularly with peritoni-tis, is an uncommon manifestation of C. neoformans infection.A high clinical suspicion and early initiation of therapy isneeded to recognize and treat patients effectively. Diagn. Cyto-pathol. 2011;39:365–367. ' 2010 Wiley-Liss, Inc.
Key Words: Cryptococcus neoformans; peritonitis; HIV positive
Cryptococcus neoformans is a ubiquitous encapsulated
yeast that predominately causes significant infections in
immunocompromised individuals, with 80–90% of all
cases occurring in those with human immunodeficiency
virus (HIV) infection.1–3 The most common sites of infec-
tion are the central nervous system and lungs.1,4 Dissemi-
nated disease is uncommon and when present almost
always occurs in HIV-infected patients.5 Cryptococcal
peritonitis is considered a rare manifestation of dissemi-
nated cryptococcosis.2 Here, we present a case of dissemi-
nated cryptococcosis with manifestation in the form of
peritonitis exclusively.
Case Presentation
A 43-year-old immunocompromised male (CD4 count of
46 cells mm�3) presented with a history of distention of
abdomen for 1 month. It was insidious in onset, gradually
progressive associated with history of on and off, nonbili-
ous nonprojectile vomiting, and history of breathlessness
on exertion, with generalized malaise. The patient was
clinically diagnosed as tubercular abdomen and was
started on direct observed treatment strategy for tubercu-
losis Category II. Patient also gave a positive history of
pulmonary tuberculosis 20 years back.
On clinical examination—abdomen was distended,
flanks were full and shifting dullness was present, no
dilated veins were seen. Hepatosplenomegaly was absent.
Clinical diagnosis of abdominal tuberculosis along with
peritonitis was kept.
Investigation: laboratory studies were unremarkable,
with no leukocytosis.
USG abdomen revealed multiple abdominal lymph
nodes along with free fluid.
Ascitic fluid cytology: the peritoneal fluid was bloody and
the cytological smears revealed reactive mesothelial cells,
macrophages, few lymphocytes, and fungal yeasts. The fungi
had thick sharply demarcated transparent capsule, supporting
the diagnosis of Cryptococcus species (Fig. 1).
Discussion
This case report presents one of the rare manifestation of
C. neoformans infection, i.e., peritonitis in immunocom-
promised patient. The menace of cryptococcosis has
assumed global proportions over the years. The tropical
climate of the Indian subcontinent offers a suitable envi-
ronment for C. neoformans, and the onslaught of the
acquired immune deficiency syndrome (AIDS) pandemic
Department of Pathology, Mahatma Gandhi Institute of Medical Scien-ces, Sevagram, Wardha, Maharashtra, India
Dr. P. Singh and Dr. D. Joshi contributed to the literature search, datacollection, data analysis, and manuscript preparation. Dr. N. Ganganegave the cytology impression. All authors have read and approved thesubmitted manuscript.
*Correspondence to: Nitin Gangane, M.D., D.N.B., Department ofPathology, Mahatma Gandhi Institute of Medical Sciences, Sevagram,Wardha, Maharashtra, India. E-mail: [email protected]
Received 4 February 2010; Accepted 17 April 2010DOI 10.1002/dc.21445Published online 2 November 2010 in Wiley Online Library
(wileyonlinelibrary.com).
' 2010 WILEY-LISS, INC. Diagnostic Cytopathology, Vol 39, No 5 365
since the early 1990s has substantially influenced the situa-
tion. Coupled with that are the advances in laboratory diag-
nostic techniques that have made accurate diagnosis increas-
ingly available. These factors together have led to a sharp
increase in the number of reported cases of cryptococcosis.6
C. neoformans has two variant forms: C. neoformansvar neoformans and C. neoformans var gatti. C. neofor-mans var neoformans is distributed worldwide and respon-
sible for most infections in humans. C. neoformans var
gatti mainly causes infection in immunocompetent hosts
and has restricted geographical distribution. In addition to
HIV infection, immunosuppressive medications, solid–
organ transplantation, chronic organ failure (renal and
liver), hematologic malignancy, chronic lung disease, and
rheumatologic disorders can also predispose individuals to
this infection. The usual manifestations are pulmonary,
but meningitis, septicaemia ocular and gastrointestinal
manifestations have also been reported.7,8
Although, the gastrointestinal tract (GIT) has been pro-
posed as a potential site for disseminated cryptococcal
infection. It is one of its rare presentations.1,9
Abdominal pain, increased abdominal girth, fever, and
dyspnea are typical complaints of patients with cryptococ-
cal peritonitis.10–13 In patients with cryptococcal peritoni-
tis, diagnosis can often be delayed due to lack of specific
signs and symptoms and low clinical suspicion among
healthcare providers.2,7 The proposed mechanisms under-
lying the pathogenesis of cryptococcal peritonitis include
direct percutaneous inoculation of contaminating organ-
isms during repeated paracentesis for management of asci-
tes, hematogenous spread from a pulmonary site, and he-
matogenous spread from the alimentary tract facilitated
by upper GI bleeding.
Various studies have described cryptococcal infection
in association with liver diseases (mainly alcoholic liver
disease, cirrhosis, or hepatitis B and C infection), the
summarized tabulated format has been given by Saif and
Raj.14 We are hereby presenting the tabulated summary
of all the case series in which gastrointestinal manifesta-
tions of cryptococcal infections occurred in association
with AIDS as shown in Table I. Stiefel et al.9 reported
Cryptococcus in ascitic fluid along with specimens such
as blood, feces, and sputum. Bonacini et al.,11 Washing-
ton et al.,8 and Saha et al.7 obtained Cryptococcus in the
biopsy of the GIT organs with negative ascitic fluid cytol-
ogy. Saha et al.7 and Sungkanuparph et al.15 also reported
reduced CD4 cell count in blood.
Cryptococcal organisms are diagnosed on cytology on
the basis of their characteristic morphological appear-
ance—yeast-like encapsulated organisms with mucicar-
mine/PAS positive capsule, which can be highlighted by
Fig. 1. Ascitic fluid cytology showing RBC and cryptococci with theircharacteristic capsule (Giemsa, 3400). [Color figure can be viewed inthe online issue, which is available at wileyonlinelibrary.com.]
Table I. Cryptococcal GIT Manifestations in Association With AIDS
S. No. Author and yearNo. ofcases Clinical diagnosis Ascitic fluid profile Other culture specimens
1 Bonacini et al., 199011 3 AIDS with GITinvolvement
Ascitic fluid culture—negative
Stomach, colon, liver, pancreasbiopsy—positive forCryptococcus
2 Washington et al., 19928 1 AIDS with candidaloesophagitisand gastric nodule
Ascitic fluid culture—negative
Gastric nodule biopsy—positivefor Cryptococcus
3 Stiefel et al., 19999 1 Cirrhosis, HepatitisC, and AIDS
Ascitic fluid profile:WBC-200/l andprotein 15.2 g/L,Cryptococcus seen
Blood, Feces, sputum—positivefor Cryptococcus
4 Sungkanuparph et al., 200215 1 Alcoholic cirrhosis;AIDS
Ascitic fluid profile:WBC-200/l andprotein 1.7 g/L
Blood—positive for CryptococcusCD4 cell count 75/cumm
5 Saha et al., 20087 1 Jejunal perforation Ascitic fluid culture—negative
Jejunal edge biopsy—positive forCryptococcus and ELISA—HIV1, CD4 count—200 cells cumm
SINGH ET AL.
366 Diagnostic Cytopathology, Vol 39, No 5
Diagnostic Cytopathology DOI 10.1002/dc
use of India ink stain. Species determination requires
culture.9,10,13
With the help of a simple, inexpensive and noninvasive
test like ascitic fluid cytology, we were able to diagnose
cryptococcal organisms in ascitic fluid of an immunocom-
promised patient. Although cryptococcal peritonitis is an
unusual manifestation of AIDS, possibility of this should
be kept in mind, especially in a patient with low CD4
counts presenting with abdominal symptoms.
Conclusions
In summary, disseminated cryptococcosis, particularly
with peritonitis, is an uncommon manifestation of C. neo-formans infection in HIV positive patients. Although the
gold standard for confirming the diagnosis is culture, but
this usually takes days and sometimes weeks where
patients may succumb to disseminated cryptococcosis.
The cytological identification is simple, fast, and cost
effective. Diagnosis of cryptococcal peritonitis can be
delayed if cytological examination is not utilized.
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CRYPTOCOCCAL PERITONITIS IN HIV POSITIVE HOST
Diagnostic Cytopathology, Vol 39, No 5 367
Diagnostic Cytopathology DOI 10.1002/dc