2014 JOURNAL OF MEDICAL RESEARCHVol.1 No.1Vol.1Jul.–Dec. 2014ERA’S JOURNAL OF MEDICAL RESEARCHJul.–Dec. No.1ERA’S
A RARE CASE oF PRIMARY lYMPHoNoDUlAR CRYPToCoCCoSIS IN
HIV PoSITIVE PATIENT oN ANTI–RETRoVIRAl THERAPY
M. Yendigeri S1 Ahmad S2 Patil A.M.1 Arifulla K M1 Fatima N1 Kolur A1, Professor & Head, Associate Professor,
Assistant Professor, Department of Pathology, Al Ameen Medical College, Athani Road, Bijapur–586108 (Karnataka)1
Department of Pathology, Era’s Lucknow Medical College, Hardoi Road, Lucknow–226003, Uttar Pradesh2.
Address for Correspondence
Cryptococcal infection is the most common life threatening opportunistic fungal infection in Dr. S M Yendigeri
Human Immunodeficiency Virus infected individuals. (1) An early diagnosis is essential for Department of Pathology,
a prompt treatment and to prevent dissemination, which is fatal. Pulmonary, intestinal, bone Al Ameen Medical College,
marrow and CNS involvement have been reported. There are only few cases of lymphonodular ABijapur–586108 (Karnataka)
Cryptococcosis have been reported, we report a rare case of primary lymphonodular Ph.No.: 9448210557
cryptococcosis without any pulmonary or CNS involvement. (2)
Key Words: Cryptococcosis, FNAC, HIV, ART, Lymphonodular.
INTRoD UCTIoNto be clear. Cerebrospinal fluid Analysis was normal. CD4
Early in the epidemic, approximately 5–8% of patients with Counts were 185 cells / L.
AIDS developed cryptococcal infection. Where effective FNAC of cervical lymphnode was performed which yielded
antiretroviral treatment (ART) is available, the incidence of white granular material. Microscopically, Hematoxylin &
cryptococcosis, along with other opportunistic infections, Eosin (H&E) stained smears showed organisms of varying
has decreased (3).size both intra and extracellular arranged in clusters, budding
The majority of AIDS isolates are Cryptococcus neoformans. forms and in single dispersed forms. The organisms were
There are 4 serotypes, designated as A, B, C, and D based ovoid, encapsulated measuring 5–20 microns, surrounded by
on antigenic determinants on the polysaccharide capsule. halo, within macrophages, suggesting cryptococcal yeast with
Serotypes A and D are the most common cause of infection, chronic inflammatory cells in the background. (Figure1).
and 90% of these infections occur in immuno compromised Special stains such as Periodic Acid Shiff, Mucicarmine
hosts (4). C. neoformans is an encapsulated, round–to–oval yeast and India ink preparation demonstrated the capsule. Ziehl
measuring 5–15 microns with a surrounding polysaccharide Neelsen stain did not reveal acid fast bacilli thus ruling
capsule(5). It grows readily from soil contaminated with out coexisting tubercular infection. It was confirmed as
avian excreta, particularly those of pigeons; possibly because lymphonodular cryptococcosis.
excreta are rich in xanthine, creatinine, urea, and uric acid, all Culture on Sabouraud Dextrose Agar showed cream colored
of which Cryptococcus can assimilate. (6)smooth mucoid colonies turning the medium bright red on
CASE REPoRT5 day
A 30 years known HIV positive male on ART presented with
solitary cervical lymphnode enlargement since 1 month with
H/o of intermittent fever of 2 months duration. A clinical
diagnosis of tubercular lymphadenitis was made and referred
for Fine Needle Aspiration Cytology (FNAC).
Clinically, patient was emaciated, febrile, conscious and
oriented. A solitary lymphnode enlargement on right side of
neck in anterior triangle measuring 2 X 2 cm, firm to hard in
consistency, non–tender, freely mobile. Systemic examination
revealed no significant findings.FigureEJMR 1 Photomicrograph showing Cryptococci
His blood counts revealed moderate anemia, neutrophilic (H&E 200 X)
leucocytosis with raised Erythrocyte Sedimentation Rate.
Biochemical investigations were within normal limits. HIV
was positive on rapid card method which was later confirmed
on ELISA and Westernblot’s method, Chest X–ray was found
2829 2014 JOURNAL OF MEDICAL RESEARCHVol.1 No.1Vol.1Jul.–Dec. 2014ERA’S JOURNAL OF MEDICAL RESEARCHJul.–Dec. No.1ERA’S
An effective ART can boost the T cell count up so the risk of
opportunistic infections can decline with ongoing treatment.
The number of cases of cryptococcosis has declined since
ART became available, although this infection is still a
relatively common AIDS–defining illness in people who
do not take HIV medications. Cryptococcosis presenting
primarily as peripheral lymphadenopathy in the absence of
pulmonary or cerebromeningeal involvement is rare. We are
reporting this case of primary lymphonodular cryptococcosis
in an HIV patient who is on ART to emphasize the role of
Figure 2 Photomicrograph showing capsule FNAC in diagnosing this lesion with minimal complications
(India Ink 200 X)highlighting early diagnosis and prompt treatment.
1. M ichaels SH , Clark R, Kissinger P, Incidence and spectrum
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in immuno–competent hosts. Immuno–compromised hosts 2008 oct; 25(4).
develop disseminated disease involving multiple systems. 3. Holtzer CD et al, Decline in the rate of specific opportunistic
It has gained recent importance because of rapid rise in infections at San Francisco General Hospital , 1994–97. AIDS
incidence of HIV infection.1998 ; 12:1931–3.
Lymphonodular cryptococcosis is an uncommon form of 4. Levitz SM .The ecology of Cryptococcus neoformans and
extra pulmonary cryptococcosis, which is one of the AIDS the epidemiology of Cryptococcosis . Rev. Infect. Dis
defining criteria according to CDC guidelines. FNAC is an 1991;13:1163–9
ideal first line diagnostic technique that provides definitive 5. Garbyal R.S et al. Cryptococcal lymphadenitis, Report of a case
diagnosis, considering the wide differential diagnosis in with FNAC. Varanasi: Banaras Hindu University, Department
immuno–compromised patients for initiating early treatment.of Pathology.
Although the overall incidence of cryptococcosis is unknown, 6. Perfect JR . Cryptococcosis. Infect Dis. Clin. North Am
it is higher among patients with AIDS in Africa and Southeast 1989;3:77–102.
Asia than in the United States. In the developed world, the 7. Arti R. Anvikar et al. Cyto diagnosisof co existance of
introduction of potent ART resulted in a decrease in the cryptococcal and mycobacterial lymphadenitis in a case of
incidence of opportunistic infections associated with AIDS.AIDS.pathology. Miraj: Government Medical college, Department of