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Table of Contents   
CASE REPORT  
Year : 2013  |  Volume : 6  |  Issue : 6  |  Page : 668-670
Cryptococcal supraclavicular lymphadenitis: A primary manifestation in AIDS-unusual presentation


Department of Pathology, Padmashree Dr. Dnyandeo Yashwantrao Patil Medical College, Hospital and Research Centre, Dr. Dnyandeo Yashwantrao Patil Vidyapeeth Pune (Deemed University), Pimpri, Pune, Maharasthra, India

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Date of Web Publication6-Sep-2014
 

   Abstract 

Cryptococcosis is a systemic infectious disease caused by Cryptococcus neoformans which is a yeast-like fungus. It can be one of the opportunistic infections in AIDS. Lymph node involvement is usually a part of disseminated disease. Isolated cryptococcal supraclavicular lymphadenitis alone is a very uncommon primary manifestation in AIDS. Once it disseminates, it can be life-threatening. Early diagnosis by fine needle aspiration is essential and reduces the morbidity and mortality.

Keywords: AIDS, cryptococcosis, fine needle aspiration cytology, lymphadenitis

How to cite this article:
Chandanwale SS, Buch AC, Vimal SS, Kshirsagar SM. Cryptococcal supraclavicular lymphadenitis: A primary manifestation in AIDS-unusual presentation. Ann Trop Med Public Health 2013;6:668-70

How to cite this URL:
Chandanwale SS, Buch AC, Vimal SS, Kshirsagar SM. Cryptococcal supraclavicular lymphadenitis: A primary manifestation in AIDS-unusual presentation. Ann Trop Med Public Health [serial online] 2013 [cited 2020 Feb 23];6:668-70. Available from: http://www.atmph.org/text.asp?2013/6/6/668/140253

   Introduction Top


Clinical manifestations and opportunistic infections associated with human immunodeficiency virus (HIV) infection may differ in different parts of the world. Many reports from India suggest that mycobacterium tuberculosis, oral candidacies, cryptosporidiosis, and pneumocystis carini are common opportunistic infections in AIDS, followed by cryptococcosis and toxoplasmosis. [1] Cryptococcosis is a life-threatening disease in AIDS patients and other forms of immunosuppression. It occurs following inhalation of the yeast of the fungus, Cryptococcus neoformans. Primary site of infection in humans is almost always respiratory tract. Secondary involvement of central nervous system, lungs, skin, lymph nodes, bone marrow, gastrointestinal tract, retina, liver, spleen, and other parts of the body can occur. [2],[3] Involvement of lymph node in cryptococcosis is considered to be rare and is usually observed in cases where the disease is widely disseminated. Cryptococcal lymphadenitis is not a common primary manifestation in either immunocompromised or immunocompetent persons though few reports have been published. [4],[5] Only involvement of supraclavicular lymph nodes by cryptococcosis is not reported as a presenting symptom in AIDS. Once cryptococcal infection disseminates, it becomes life-threatening. Expeditious early diagnosis is of the utmost importance.


   Case Report Top


Thirty-three years old male was referred to cytology clinic with enlarged lymph nodes in right supraclavicular region of the neck. On examination, 2-3 matted cervical lymph nodes mass measuring 0.8-1.5 cm was palpated. Axiliary or inguinal lymph nodes were not palpable. Patient had a history of fever and weight loss since 15 days. There was no history of cough, expectoration, and headache. Clinically, mycobacterium tuberculosis was suspected. fine needle aspiration (FNA) yielded scanty necrotic material. Material obtained was smeared on glass slides. One smear was air dried and stained with Leishman's stain. One smear was stained with Ziehl-Neelsen (ZN) stain for detecting acid fast bacilli (AFB). Smears showed on hemorrhagic background, few lymphocytes, and scattered ovoid encapsulated organisms (yeast) varying from 05 to 12 μm in diameter [Figure 1]. Cryptococcal infection was suspected. AFB was not seen on ZN stain. Second aspirate was done and smears were stained with mucicarmine stain. Microscopy showed yeast with intense red capsule with vague empty appearance of internal structure [Figure 2]. Diagnosis of cryptococcal lymphadenitis was made. Subsequent investigations revealed, patient was reactive by enzyme-linked immunosorbent assay for HIV. No other significant medical findings were seen. Radiograph and computerized tomography scan of chest was normal.
Figure 1: FNA smears show many scattered ovoid encapsulated yeast of Cryptococcus neoformans (Leishman stain, ×400)

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Figure 2: FNA smears show capsule of the Cryptococcus neoformans (mucicarmine stain, ×400)

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   Discussion Top


Cryptococcosis is a systemic infectious disease caused by inhalation of yeast like fungus, C. neoformans. Infection by transplanted organ is possible. It is frequently found in soil contaminated with bird droppings particularly those of pigeons. Though it is classified as a primary pathogen, it is often encountered as a cause of opportunistic infection more often in AIDS. It may cause an asymptomatic pulmonary infection, sometimes followed by meningitis, pneumonia, pulmonary nodules, or mass lesions. Generally it starts as a primary pulmonary lymph node complex. In immunocompetent person, it becomes fibrosed and remains occult. In immunocompromised person, it disseminates with predominant organ localization. Lymph node involvement is usually a part of disseminated disease. Very rarely, they may be affected in relation to occult focus of cryptococcosis, which might have happened in our case. [6] Cryptococcal meningitis and disseminated cryptococcosis have gained importance recently because of rapid rise in the worldwide incidence of HIV infection. In our case, supraclavicular lymph nodes involvement alone by cryptococcosis is very unusual. Cryptococcosis is one of the AIDS defining criteria according to the Center for Disease Control and Prevention guidelines. [7] Cryptococcus is yeast-like budding fungi, appear as ovoid to spherical thick-walled surrounded by gelatinous capsule, and difficult to differentiate from blastomyces. Unlike other fungal infections, granulomatous and other inflammatory cell responses are very mild which was also in our case. Organism load is variable, more in immunocompromised as compared to immunocompetent patients which was seen in our case too. [5] Laboratory diagnosis of cryptococcal infection includes the use of special stains such as India Ink, periodic-acid Schiff-Alcian blue, and mucicarmine stains. Serological detection of cryptococcus antigens by latex agglutination and culture are also used.

Fine needle aspiration cytology does provide the economical and rather quickly accomplished cytodiagnostic result. Patient was treated with fluconazol and showed improvement clinically. Patient was also started highly active antiretroviral therapy and is closely monitored. This case is presented to highlight cryptococcus infection presenting primarily with supraclavicular lymphadenitis in AIDS patient which is very unusual. Early correct diagnosis reduces morbidity and mortality which happened in our case.


   Conclusion Top


We conclude that in AIDS, cryptococcal supraclavicular lymphadenitis alone can be a presenting symptom. Early diagnosis by FNA helps to initiate prompt treatment and reduce morbidity and mortality.

 
   References Top

1.Singh A, Bairy I, Shivananda PG. Spectrum of opportunistic infections in AIDS cases. Indian J Med Sci 2003;57:16-21.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Chayakukeeree M, Perfect JR. Cryptococcosis. Infect Dis Clin North Am 2006;20:507-44.  Back to cited text no. 2
    
3.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. 3
[PUBMED]  Medknow Journal  
4.Garbal RS, Basu D, Roy S, Kumar S. Cryptococcal lymphadenitis: Report of a case with fine needle aspiration cytology. Acta Cytol 2005;49:58-60.  Back to cited text no. 4
    
5.Srinivas R, Gupta N, Shifa R, Malhotra P, Rajwanshi A, Chakrabarti A. Cryptococcal lymphadenitis diagnosed by fine needle aspiration cytology: A review of 15 cases. Acta Cytol 2010;54:1-4.  Back to cited text no. 5
    
6.Baker RD. The primary pulmonary lymph node complex of cryptococcosis. Am J Clin Pathol 1976;65:83-92.  Back to cited text no. 6
    
7.Suchitra S, Sheeladevi CS, Sunila R, Manjunath GV. FNA diagnosis of Cryptococcal lymphadenitis: A window of opportunity. J Cytol 2008;25:147-49.  Back to cited text no. 7
    

Top
Correspondence Address:
Shirish S Chandanwale
Department of Pathology, Padmashree Dr. Dnyandeo Yashwantrao Patil Medical College, Hospital and Research Centre, Dr. Dnyandeo Yashwantrao Patil Vidyapeeth Pune (Deemed University), Pimpri, Pune - 411 018, Maharasthra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.140253

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