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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 51  |  Issue : 2  |  Page : 296-297
Cryptococcal neoformans profiles in peripheral blood neutrophils: An unusual presentation


Department of Hematology, AIIMS, New Delhi, India

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   Abstract 

We report an unusual observation of Cryptococcal neoformans profiles engulfed by neutrophils on a routine peripheral blood smear examination in an HIV-negative young female patient who presented with perforation of large bowel following a pregnancy termination procedure by an untrained midwife.

Keywords: Cryptococcus, neutrophils

How to cite this article:
Srinivas U, Kar R, Saxena R, Prasad PH. Cryptococcal neoformans profiles in peripheral blood neutrophils: An unusual presentation. Indian J Pathol Microbiol 2008;51:296-7

How to cite this URL:
Srinivas U, Kar R, Saxena R, Prasad PH. Cryptococcal neoformans profiles in peripheral blood neutrophils: An unusual presentation. Indian J Pathol Microbiol [serial online] 2008 [cited 2019 Oct 17];51:296-7. Available from: http://www.ijpmonline.org/text.asp?2008/51/2/296/41707



   Introduction Top


Cryptococcus neoformans is a dimorphic fungus that occurs naturally in the soil and has a propensity for causing opportunistic infection in immunocompromised patients. Disseminated cryptococcosis is uncommon in immunocompetent patients. It is usually detected by cytological examination of fluids, histopathological examination of tissues; and confirmed and speciated by fungal cultures. While isolation of cryptococci from blood cultures is not infrequent, only uncommonly are these organisms first detected on peripheral blood examination. This case highlights the importance of meticulous examination of peripheral blood smear for "opportunistic" organisms, even in an immunocompetent patient.


   Case History Top


A 28-year-old woman underwent termination of pregnancy by an untrained midwife at a rural medical center. She came the next day to the surgical emergency ward of our institute with sigmoid colonic perforation and peritonitis. After admission, she rapidly developed septicemia with features of disseminated intravascular coagulation (DIC). Serum chemistry revealed total bilirubin, 4.5 mg%; aspartate and alanine transaminases, 280 and 480 IU respectively; creatinine, 3.8 mg/dL; and blood urea nitrogen, 49 mg/dL. Serologic tests for HIV, hepatitis B and C were negative. Hematological parameters were hemoglobin, 78 g/L; total leukocyte count, 15.5 10 9 /L; and platelets, 10 10 9 /L. A routine peripheral blood smear to find clues for disseminated intravascular coagulation showed numerous refractile encapsulated organisms engulfed by neutrophils that were morphologically consistent with Cryptococcus neoformans [Figure 1A], along with fragmented RBCs and marked thrombocytopenia. They were positive for periodic acid-Schiff (PAS) [Figure 1B], mucicaramine [Figure 1C] and methenamine silver [Figure 1D]. Fungal blood cultures on Sabouraud's glucose agar subsequently confirmed Cryptococcus neoformans .

The patient's clinical course was rapidly downhill. She bled profusely per vaginum and succumbed to the disease before appropriate therapy could be instituted within 48 hours of hospitalization.


   Discussion Top


Cryptococcosis commonly presents with pulmonary, central nervous system (CNS) and/or skin involvement. Only rarely is hepatic, prostatic and marrow involvement reported. Acquired immunodeficiency syndrome (AIDS) is one of the leading causes of disseminated cryptococcosis. [1]

Diagnosis depends upon the demonstration of growth of the fungal organisms on fungal culture media with characteristic biochemical reactions (urease, phenoloxidase). Finding encapsulated yeast forms on India ink or on PAS staining followed by positive mucicaramine or silver staining and/or demonstration of cryptococcal capsular polysaccharide antigen in titers more than 1:8 in serum or cerebrospinal fluid (CSF) is also confirmatory. Our case is noteworthy in that the diagnosis of cryptococcosis was first made on a peripheral smear in a HIV-negative patient. Only a few prior reports exist where disseminated cryptococcosis was diagnosed on a peripheral blood film, nearly always in HIV/AIDS patients. [2],[3] To the best of our knowledge, cryptococcal profiles in peripheral blood neutrophils in an immunocompetent patient has not been reported.

A contributory factor to the adverse outcome in our patient was DIC. Its etiology in this patient was most likely multifactorial, with fungemia possibly compounding the obstetrical complication, intestinal perforation and peritonitis. DIC has been reported as one of the common complications of disseminated cryptococcosis in both immunocompetent and immunocompromised settings. [4] It therefore is judicious to maintain a high index of suspicion for this complication in patients with opportunistic fungal infections, who require prompt initiation of appropriate therapy.

The usual portal of entry of cryptococci is through inhalation, lungs consequently being the most common site of infection. Disseminated cryptococcosis is usually a consequence in immunodeficient conditions. In our patient, with no known risk factors for compromised immunity prior to her current illness, it may be speculated that the organism gained access to her bloodstream through the uterine and colonic perforations. Once established, the infection may have propagated unabated, contributing to her generalized debility, to the point of extensive dissemination in peripheral blood neutrophils.

In conclusion, this case serves as a reminder to the diagnostic hematopathologist of the importance of a careful "routine" peripheral blood smear examination. It highlights the fact that one should maintain a high index of suspicion for clinically unsuspected infectious agents, even in the immunocompetent host.

 
   References Top

1.Agarwal V, Sachdev A, Agarwal G, Harsh Mohan, Anjali. Disseminated cryptococcosis mimicking lymphoreticular malignancy in a HIV negative patient. JK Science 2004;6:93-5.  Back to cited text no. 1    
2.Yao JD, Arkin CF, Doweiko JP, Hammer SM. Disseminated cryptococcosis diagnosed on peripheral blood smear in a patient with acquired immunodeficiency syndrome. Am J Med 1990;89:100-2.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Revankar, SG, Gregg CR. Disseminated cryptococcosis in an AIDS patient diagnosed by examination of a peripheral blood smear. Eur J Clin Microbiol Infect Dis 2000;19:887-8.  Back to cited text no. 3    
4.Fera G, Semeraro N, De Mitrio V, Schiraldi O. Disseminated intravascular coagulation associated with disseminated cryptococcosis in a patient with acquired immunodeficiency syndrome. 1993;21:171-3.  Back to cited text no. 4    

Top
Correspondence Address:
Upendra Srinivas
Department of Hematology, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.41707

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    Figures

  [Figure 1A], [Figure 1B], [Figure 1C], [Figure 1D]

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