Cryptococcal Lymphadenitis Diagnosed by FNAC in a HIV Positive Individual

BR Shravanakumar¹, KR Iyengar¹, Y Parasappa¹, R Ramprakash²,  
¹ Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry - 605006, India
² Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry - 605006, India

Correspondence Address:
B R Shravanakumar
Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry - 605006
India

Full Text

Sir,

We recently encountered an infrequent manifestation of opportunistic fungal infection. A forty year old promiscuous male came with the history of persistent fever, on and off diarrhea for two months. The patient had palpable cervical & epitrochlear lymphnodes, each measuring 2 x 2 cm, unresponsive to antitubercular treatment. General physical examination showed many umblicated skin nodules. His vital signs, systemic examination, routine hematological as well as biochemical investigations were within normal limits.

FNAC from left epitrochlear lymphnode showed numerous refractile, round structures with clear halo in Papanicolaou stain. Mucicarmine stain confirmed them to be cryptococci by staining the capsule pink. There was no evidence of tissue response. A subsequent biopsy from the same lymphnode & one of the skin nodules confirmed the lesion. Culture studies or serologic confirmation were not performed. ELISA testing in duplicate for HIV was performed subsequently (after obtaining informed consent) which was shown to be positive. In view of the positive serology for HIV and presence of opportunistic infection, the patient was diagnosed as having AIDS. Chest X-ray was within normal limits and sputum and stool examination did not show cryptococci. CD4 counts were not performed in this patient. The patient responded initially to antifungal agents (Amphotericin B 0.7mg/kg/day I.V. for two weeks) but was lost to follow up later. Specific anti-HIV therapy was not administered to the patient.

Primary pulmonary cryptococcosis is usually acquired by inhalation of soil inhabiting yeast. Unlike healthy individuals, the immunocompromised host (e.g. hematological malignancies, AIDS, impaired cell-mediated immunity) is more susceptible for its survival and dissemination to almost all organs of the body, especially central nervous system, lungs, gastrointestinal tract and reticuloendothelial system.[1],[2],[3]

Cryptococcal lymphadenitis, though rare, affecting mediastinal and cervical nodes is well known.[4] Involvement of epitrochlear lymph node is not documented in the literature. FNAC allows rapid diagnosis of disseminated cryptococcosis.[2]

The tissue reaction to cryptococcal infection of lymph node ranges from a barely perceptible histiocytosis to a tuberculoid reaction, sometimes with heavy calcification.[4]

The fungus has an average diameter of 5-15µ and has the characteristic thick halo-like mucinous capsule made of acid mucopolysaccharides. It stains metachromatically purple with methylene blue and red with mucicarmine.[2],[4] Smaller fungal cells with thin or absent mucinous capsule may be mistaken for other organisms particularly Histoplasma capsulatum and Leishmaniae.[2]

This case is being presented to highlight the unusual presentation of epitrochlear lymphadenitis and cutaneous nodules in cryptococcal infection.

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