Journal of Cytology
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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 25  |  Issue : 4  |  Page : 147-149
Fine needle aspiration diagnosis of cryptococcal lymphadenitis: A window of opportunity


Department of Pathology, JSS Medical College, Mysore, Karnataka, India

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   Abstract 

Cryptococcal meningitis is the most common, life-threatening, opportunistic, fungal disease in human immunodeficiency virus (HIV)-infected individuals. An expeditious diagnosis is of utmost importance because once a cryptococcal infection disseminates, it becomes life-threatening. Pulmonary, intestinal, bone marrow, and retinal involvement have been described. There are very few reports, however, of lymphadenopathy along with cryptococcal meningitis. We report here a case of cryptococcal meningitis with lymphadenitis, which was diagnosed by fine needle aspiration cytology of the involved lymph nodes.

Keywords: Cryptococcal meningitis; FNAC; lymphadenopathy.

How to cite this article:
Suchitha S, Sheeladevi C S, Sunila R, Manjunath G V. Fine needle aspiration diagnosis of cryptococcal lymphadenitis: A window of opportunity. J Cytol 2008;25:147-9

How to cite this URL:
Suchitha S, Sheeladevi C S, Sunila R, Manjunath G V. Fine needle aspiration diagnosis of cryptococcal lymphadenitis: A window of opportunity. J Cytol [serial online] 2008 [cited 2020 Jun 2];25:147-9. Available from: http://www.jcytol.org/text.asp?2008/25/4/147/50801



   Introduction Top


Human immunodeficiency virus (HIV) infection has emerged as a global epidemic and India has a significant share of this global burden. [1] Cryptococcosis is a chronic or opportunistic infection caused by the encapsulated yeast, C ryptococcus neoformans . [2] The immunocompromised host is more susceptible to the survival and dissemination of this yeast, which can occur to almost all organs of the body, especially the central nervous system, lungs, bone marrow, gastrointestinal tract, retina, and the reticuloendothelial system. [3]

Lymphadenopathy presents an opportunity for a quick and efficient way to reach an early diagnosis through fine needle aspiration cytology (FNAC) of the involved lymph node. The procedure is economical and the cytodiagnosis is quickly accomplished. [4]


   Case Report Top


A 30 year-old male patient reported with fever, difficulty in swallowing, generalised weakness, headache, and vomiting of 15 days' duration. The patient had been on empirical treatment for tuberculosis for three months, which was the suspected cause of his lymphadenopathy. On examination, the patient was found to be pale and had multiple, nontender, posterior cervical, supraclavicular, axillary, and inguinal lymph nodes; the largest lymph node measured 2 x 2 cm. Oral candidiasis was observed and neck rigidity was present. Kernig's sign was positive, deep tendon reflexes were 2+, withdrawal plantar reflex was seen, and motor power was normal; there was hepatosplenomegaly. The patient was admitted with a provisional diagnosis of meningitis and for evaluation of the fever.

His blood investigations revealed a hemoglobin level of 6.8 g%, a total leukocyte count of 4,300 cells/cu. mm and an absolute lymphocyte count of 170 cells/cu. mm. Red cell indices and the platelet count were normal. Erythrocyte sedimentation rate (ESR) by Westergren's method was a 140 mm fall at the end of one hour. Total serum proteins were 7.2 g/dL, with an albumin level of 2.9 g/dL and an albumin to globulin (A:G) ratio of 0.7. Other biochemical investigations were within normal limits; HIV was reactive by ELISA method. His chest radiograph showed no radiological abnormality.

Cerebrospinal fluid (CSF) examination revealed ten lymphocytes per high power field and organisms that were morphologically consistent with cryptococci. India ink preparation and culture of the CSF confirmed the suspicion of cryptococci. FNAC of the cervical lymph nodes was performed and the smears were found to be cellular and had many epithelioid cell clusters [Figure 1]. Numerous budding yeast cells measuring 5-15 m in diameter and surrounded by halos, were identified within the macrophages and also free in the background. The capsule was identified by special stains such as periodic acid Schiff (PAS) and mucicarmine [Figure 2]. Ziehl Neelsen staining did not reveal any acid-fast bacilli, ruling out any coexisting tuberculous infection.

A diagnosis of cryptococcal lymphadenitis was made. The patient was immediately started on amphotericin infusion, but his condition deteriorated and he died shortly thereafter.


   Discussion Top


Cryptococcosis is a chronic or opportunistic infection caused by the encapsulated yeast, Cryptococcus neoformans. This organism is widely distributed throughout the globe and is abundant in pigeon droppings. The organisms easily get into the respiratory tract of human beings through inhalation. [2] Cryptococcal meningitis and disseminated cryptococcosis have gained importance recently because of the rapid rise in the worldwide incidence of HIV infection. [2] Cryptococcal lymphadenitis is an uncommon form of extrapulmonary cryptococcosis, which is one of the 'AIDS defining criteria' according to the Centre for Disease Control and Prevention (CDC) guidelines. [1],[5] Cryptococcal meningitis is the most common type of opportunistic central nervous system infection in AIDS patients in developed countries. However, in developing countries, tuberculosis is the most common cause of meningitis in AIDS patients. [2]

The clinical presentation in this case, makes tuberculosis (TB) the first differential diagnosis, especially with its high prevalence in India. [1] Starting anti-tuberculosis treatment (ATT) empirically, as it happened in this case, is a logical consequence. Although empirical therapy may be beneficial to patients in many cases, confirmation of diagnosis by histopathological / microbiological methods should always be done. [1]

Identification of cryptococcus has been reported from cytology specimens of cerebrospinal fluid, sputum, bronchial washings, and FNA smears of the lymph nodes, thyroid, spleen, adrenal gland, bones, and the lung. [6] The organism is surrounded by a mucopolysaccharide capsule and measures 5-15 m in diameter. It is a single, narrow-based, budding yeast. Special stains (Gomori's methanamine silver (GMS), PAS, and mucicarmine) facilitate the identification of this organism. Granulomatous inflammation, which may be slight or absent, can be caused by cryptococci ; [6],[7] in our case, many epithelioid granulomas were seen. Although, culture is important for identification of the pathogen, diagnosis of cryptococcosis can be made on cytologically obtained smears when the mucopolysaccharide capsule is visualised with special stains. [6]

FNAC can thus be a simple and useful technique in the diagnosis of fungal infections. Its utility is enhanced by the ability to immediately prepare smears and simultaneously obtain samples for cultures. This method can expedite the potentially vast differential diagnoses in immunocompromised patients. Identification of these organisms, with or without cellular reactions, can lead to a rapid diagnosis and importantly, an early initiation of specific and life-saving treatment.

 
   References Top

1.Tahir M, Sharma SK, Sinha S, Das CJ. Immune reconstitution inflammatory syndrome in a patient with cryptococcal lymphadenitis as the first manifestation of acquired immunodeficiency syndrome. J Postgrad Med 2007;53:250-2.  Back to cited text no. 1  [PUBMED]  Medknow Journal
2.Das BP, Panda PL, Mallik RN, Das B. Cryptococcal lymphadenitis and meningitis in human immunodeficiency virus infection: A case report. Indian J Pathol Microbiol 2002;45:349-51.  Back to cited text no. 2    
3.Shravanakumar BR, Iyengar KR, Parasappa Y, Ramprakash R. Cryptococcal lymphadenitis diagnosed by FNAC in a HIV positive individual. J Postgrad Med 2003;49:370.  Back to cited text no. 3  [PUBMED]  Medknow Journal
4.Garbyal RS, Basu D, Roy S, Kumar P. Cryptococcal lymphadenitis: Report of a case with fine needle aspiration cytology. Acta Cytol 2005;49:58-60.  Back to cited text no. 4    
5.Schneider E, Whitmore S, Glynn KM, Dominguez K, Mitsch A, McKenna MT, et al . Revised surveillance case definitions for HIV infection among adults, adolescents, and children aged <18 months and for HIV infection and AIDS among children aged 18 months to <13 years--United States, 2008. MMWR Recomm Rep 2008; 57:1-12.  Back to cited text no. 5    
6.Lee MY, Chung JH, Shin JH, Hwang TJ, Kim KS, Lee JH, et al . Lymphonodular cryptococcosis diagnosed by fine needle aspiration cytology in hyper-IgM syndrome: A case report. Acta Cytol 2001;45:241-4.  Back to cited text no. 6    
7.Kumar S, Ferns S, Jatiya L. A rare case of cryptococcosis diagnosed by fine needle aspiration cytology. Acta Cytol 2003;47:528-9.  Back to cited text no. 7    

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Correspondence Address:
S Suchitha
#892, I Block, 1st Cross, Ramakrishna Nagar, Mysore-570 022
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9371.50801

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    Figures

  [Figure 1], [Figure 2]

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