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: nitingangane@rediffmail.com

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.

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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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