AJR 2003; 181:1055-1057
© American Roentgen Ray Society
Simultaneous Thoracic and Abdominal Presentation of Disseminated Cryptococcosis in Two Patients Without HIV Infection
Do Youn Kim1,
Yookyung Kim1,
Seung Yon Baek1 and
Hye-Kyung Yoon2
1 Department of Radiology, Ewha Womans University MokDong Hospital, 911-1
MokDong YangCheon-Ku, Seoul 158-710, South Korea.
2 Department of Radiology, Samsung Medical Center, Sungkyunkwan University
School of Medicine, Seoul 135-230, South Korea.
Received October 21, 2002;
accepted after revision January 28, 2003.
Address correspondence to Y. Kim.
Introduction
Disseminated cryptococcosis commonly occurs in immunocompromised patients,
particularly in HIV-infected patients, and rarely in immuno-competent
patients. In patients with disseminated disease, meningitis is the form most
frequently observed [1];
disseminated disease affecting predominantly the lung and abdominal organs is
rare [2]. To our knowledge, no
report has described the CT features of disseminated cryptococcosis
concomitantly involving the thorax and abdomen. We describe two cases of
disseminated cryptococcosis that primarily affected the lung, lymph nodes,
liver, and spleen in patients without HIV infection.
Case Report
A previously healthy 23-year-old woman presented with a 15-day history of
abdominal pain, fever, and night sweats. At physical examination, enlarged
lymph nodes were palpable in the neck. Laboratory tests revealed an increased
WBC of 13,900/µL and increased erythrocyte sedimentation rate of 105 mm/hr.
Results of the liver function test were within acceptable limits. A chest
radiograph obtained at admission showed bilateral multiple small nodules and
patchy consolidations in the lung and bilateral hilar enlargement. A
contrast-enhanced chest CT scan revealed mediastinal and hilar lymphadenopathy
and small bilateral pleural effusions (Fig.
1A). Left hilar lymphadenopathy had central low attenuation.
Thin-section CT revealed multiple micronodules showing peripheral, subpleural,
and fissural locations and patchy consolidations in the lung
(Fig. 1B). A contrast-enhanced
abdominal CT revealed multiple low-attenuation lesions throughout the liver
and spleen. Some abdominal lymphadenopathy had central low attenuation
(Fig. 1C). Results of blood and
sputum cultures were negative.
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Fig. 1A. —23-year-old immunocompetent woman who presented with
abdominal pain and fever. Contrast-enhanced CT scan (10-mm collimation)
obtained at level of subcarina shows enlarged subcarinal and left hilar lymph
nodes and small pleural effusions. Left hilar lymph node shows central low
attenuation.
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Fig. 1B. —23-year-old immunocompetent woman who presented with
abdominal pain and fever. Thin-section CT scan (1.5-mm collimation) shows
multiple small nodules in both lungs, predominantly in peripheral lung, and
patchy consolidation in lingular segment. Also note subpleural and fissural
micronodules.
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Fig. 1C. —23-year-old immunocompetent woman who presented with
abdominal pain and fever. Contrast-enhanced CT scan obtained at level of renal
artery shows enlarged lymph nodes. Note central low attenuation in porta
hepatis, portocaval space, and retroperitoneum. Low-density lesions are also
present in spleen. Similar low-density lesions (not shown) were present in
liver at other levels.
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Surgical biopsy of one of the cervical lymph nodes was performed.
Histologic examination revealed granulomatous inflammation and the
mucicarmine, PAS, and Gomori's methenamine silver stains showed cryptococcal
organisms in the multinucleated giant cells. A serum cryptococcal antigen test
result was negative. The patient was treated with IV amphotericin B (Ambisome,
Yuhan, Seoul, South Korea) and then with oral fluconazole (Diflucan, Pfizer
Korea, Seoul, South Korea). The pulmonary lesions and bilateral hilar
lymphadenopathy were less pronounced on follow-up chest radiographs.
In the second case, a 12-year-old boy who had been diagnosed with
hyperimmunoglobulin M syndrome 2 years earlier was admitted because of
palpable neck masses and diarrhea. At physical examination, enlarged cervical
lymph nodes were palpable. Contrast-enhanced chest and abdominal CT scans
revealed lymphadenopathy in the thorax and abdomen (Figs.
2A and
2B) and multiple
low-attenuation lesions in the liver and in the enlarged spleen
(Fig. 2B). Surgical biopsies of
the cervical lymph nodes, liver, and spleen were performed, and histologic
examination showed cryptococcal organisms.
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Fig. 2A. —12-year-old boy with hyperimmunoglobulin M syndrome who
presented with palpable neck masses and diarrhea. Contrast-enhanced CT scan
(7-mm collimation) obtained at level of aortic arch shows multiple enlarged
mediastinal lymph nodes.
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Fig. 2B. —12-year-old boy with hyperimmunoglobulin M syndrome who
presented with palpable neck masses and diarrhea. Contrast-enhanced CT scan
obtained at level of renal artery shows markedly enlarged lymph nodes in porta
hepatis, portocaval space, and retroperitoneum. Multiple small lowattenuation
lesions (not shown) were also present in liver and in enlarged spleen.
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Discussion
Cryptococcus neoformans is a nonmycelial budding yeast found in
soil contaminated by droppings of birds, especially pigeons. Cryptococcal
infection usually results from inhalation of the yeast spores. Depending on
the host's immune status, the infection may remain isolated in the lungs or
undergo hematogenous spread to involve the central nervous system, bones, and
skin.
Disseminated cryptococcosis commonly occurs in HIV-infected patients and is
found less frequently in non-HIV patients who have compromised host immunity.
Disseminated disease rarely occurs in an immunocompetent patient
[3]. In one of our two
patients, no underlying immune disturbance was evident. Although disseminated
disease may affect virtually any organ, meningoencephalitis or meningitis
occur most frequently, followed by pneumonia
[1]. Disseminated disease
initially presenting with simultaneous thoracic and abdominal disease is rare,
and diagnosis is difficult in most cases, particularly in patients without HIV
infection, because of its infrequency and the nonspecific clinical findings of
systemic infection. In previous reports of patients with disseminated
cryptococcosis predominantly affecting abdominal organs, diagnosis was usually
confirmed by open liver or lymph node biopsy
[2].
In patients with disseminated cryptococcosis, pulmonary manifestations are
diverse and radiographic findings include normal nodular or circumscribed
infiltrates, pleural effusions, and lobar consolidation
[4]. One of the patients
presented with a micronodular pattern showing peripheral, subpleural, and
fissural locations, which is suggestive of hematogenous dissemination.
Lymphadenopathy in the thorax and abdomen was present in both patients, and
one patient had necrotic lymph nodes. Lymphadenopathy in patients with
cryptococcal infection is a common feature of disseminated disease, although
it may present in nondisseminated infection
[5]. Necrotic lymph nodes may
be present, particularly in AIDS patients
[6]. Necrotic lymph nodes with
low attenuation on contrast-enhanced CT have been described as characteristic
of granulomatous infections, including mycobacterial and fungal infections,
although they may also be noted in other diseases such as metastasis,
lymphoma, and Whipple's disease
[6].
Disseminated fungal infection with hepatosplenic microabscesses commonly
occur in immunocompromised patients, particularly in patients with hematologic
malignancy treated with cytotoxic drugs. The most common pathogens are
Candida, followed by Aspergillus organisms
[7]. Disseminated
cryptococcosis presenting with hepatosplenic microabscesses is rare. CT
findings include multiple low-attenuation lesions in the liver and spleen,
which are usually 5–10 mm in diameter on contrast-enhanced scans. In our
patients, microabscesses appeared as poorly defined low-attenuation lesions,
often with a central area of lower attenuation. The CT finding of multiple
low-attenuation lesions in the liver and spleen of patients with suspected
systemic infection is not pathognomonic for fungal infection and may also be
observed in patients with disseminated mycobacterial infection
[8].
Differential diagnosis of lymphadenopathy, multiple low-attenuation lesions
in the liver and spleen, and pulmonary nodules on CT includes disseminated
fungal or mycobacterial infections, metastasis, lymphoma, and sarcoidosis.
In conclusion, on the basis of observations made in these cases,
disseminated cryptococcosis should be included in the differential diagnosis
of any patient with suspected systemic infection and CT findings of
thoracoabdominal lymphadenopathy and hepatosplenic microabscesses with or
without pulmonary nodules or consolidation, regardless of the immune
status.
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Introduction
Case Report
