LGCmain
Indian Journal of Pathology and Microbiology
Home About us Instructions Submission Subscribe Advertise Contact e-Alerts Ahead Of Print Login 
Users Online: 2097
Print this page  Email this page Bookmark this page Small font sizeDefault font sizeIncrease font size
IJPM is coming out with a Special issue on "Genitourinary & Gynecological pathology including Breast". Please submit your articles for these issues


 
LETTER TO EDITOR Table of Contents   
Year : 2010  |  Volume : 53  |  Issue : 4  |  Page : 904-906
Acquired immunodeficiency syndrome presenting as marrow cryptococcosis


Department of Pathology, PSG Institute of Medical Sciences & Research, Peelamedu, Coimbatore, India

Click here for correspondence address and email

Date of Web Publication27-Oct-2010
 

How to cite this article:
Venkatachala S, Naik DR, Shanthakumari S, Jayaraman A. Acquired immunodeficiency syndrome presenting as marrow cryptococcosis. Indian J Pathol Microbiol 2010;53:904-6

How to cite this URL:
Venkatachala S, Naik DR, Shanthakumari S, Jayaraman A. Acquired immunodeficiency syndrome presenting as marrow cryptococcosis. Indian J Pathol Microbiol [serial online] 2010 [cited 2019 Dec 12];53:904-6. Available from: http://www.ijpmonline.org/text.asp?2010/53/4/904/72069


Sir,

A male aged 47 years with serologically established Human Immunodeficiency Virus (HIV) infection presented with loss of weight and appetite. There was no history of headache, vomiting or seizures. On examination, hepatosplenomegaly was noted. There were no signs of meningeal irritation. A complete blood picture revealed pancytopenia. Hemoglobin was 8.4 g/dl, total leukocyte count was 2.7 × 10 9 /l, platelet count was 75 × 10 9 /l and erythrocyte sedimentation rate was 77 mm fall in the first hour. Bone marrow aspiration was done to evaluate the cause of pancytopenia. Leishman stained smears revealed normocellular marrow with megaloblastic erythropoiesis. The myeloid and megakaryocytic series were unremarkable. In addition, plasmacytosis of 14% was observed. Interspersed between the hemopoietic cells were seen small, refractile, capsulated, budding organisms, morphologically consistent with cryptococci [Figure 1]. Special stains such as mucicarmine, periodic acid Schiff (PAS) [Figure 2] and Gomori's methanamine silver (GMS) [Figure 3] were used, which highlighted the capsule. No granulomas were seen in the smears.
Figure 1: Showing cryptococci interspersed with hemopoietic cells (Leishman stain, ×1000)

Click here to view
Figure 2: Showing polysaccharide rich cryptococcal capsule (PAS, ×1000)

Click here to view
Figure 3: Showing budding yeast forms (GMS, ×400)

Click here to view


Subsequently, cerebrospinal fluid (CSF) examination was done and India ink preparation demonstrated cryptococci. This case was unique in that the identification of cryptococci in the marrow aspirate was the first clue for the diagnosis disseminated cryptococcosis.

Cryptococcosis is seen in 6-10% of acquired immune-deficiency syndrome (AIDS) patients. [1] Among the fungal infections that prey on HIV infected individuals, it is second only to candidiasis. Dissemination cryptococcal infection is an uncommon initial manifestation in patients with AIDS, the most common sites of involvement being the central nervous system and/or lungs. The involvement of marrow is rare. [2] Most patients present with a picture of sub-acute meningo-encephalitis. Pulmonary cryptococcosis can follow an indolent course and may not come to clinical attention. Our patient presented with loss of weight and appetite and had no central nervous system symptoms. This is a rare mode of presentation. Similar presentation has been reported by Wong et al.[2]

The rate of finding the cryptococci in the marrow in patients with AIDS has been low. [3] A granulomatous response has been described in a few cases of Cryptococcus neoformans, with the number of organisms being inversely proportional to the response. [3] No granulomas were seen in the marrow in our case.

Bone marrow morphology is frequently abnormal in patients with AIDS. The most common findings are myelodysplasia, megaloblastic hematopoiesis, fibrosis, plasmacytosis, lymphoid aggregates and granulomas. [4],[5] The bone marrow in this case showed megaloblastic erythropoiesis with plasmacytosis of 14%.

Infection of bone marrow with cryptococci may act in synergy with HIV to cause cytopenia. [4] Bone marrow aspiration should be performed to elucidate the etiology of cytopenias, secondary infections and fever of undetermined origin in AIDS patients. Other studies have also reinforced the role of bone marrow examination for the diagnosis of opportunistic infections in AIDS. [5]

 
   References Top

1.Abbas AK. Diseases of immunity. In: Kumar V, Abbas AK, Fausto N, editors. Robbins and Cotran Pathologic Basis of Disease. 7 th ed. India: Thomson press; 2004. p. 255-6.  Back to cited text no. 1
    
2.Wong KF, Ma SK, Chan JK, Lam LW. Acquired immunodeficiency syndrome presenting as marrow cryptococcosis. Am J Hematol 1993;42:392-4.  Back to cited text no. 2
    
3.Nichols L, Florentine B, Lewis W, Sattler F, Rarick MU, Brynes RK. Bone marrow examination for the diagnosis of mycobacterial and fungal infection in AIDS. Arch Pathol Lab Med 1991;115:1125-32.  Back to cited text no. 3
[PUBMED]    
4.Karcher DS, Frost AR. The bone marrow in human immunodeficiency virus-related disease. Morphology and clinical correlation. Am J Clin Pathol 1991;95:63-71.  Back to cited text no. 4
[PUBMED]    
5.Khandekar MM, Deshmukh SD, Holla VV, Rane SR, Kakrani AL, Bollinger RC. Profile of bone marrow examination in HIV/AIDS patients to detect opportunistic infections, especially tuberculosis. Indian J Pathol Microbiol 2005;48:7-12.  Back to cited text no. 5
    

Top
Correspondence Address:
Sandhya Venkatachala
PSG Institute of Medical Sciences, Peelamedu, Coimbatore - 641 004
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.72069

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3]

This article has been cited by
1 Skeletal cryptococcosis from 1977 to 2013
Heng-Xing Zhou,Lu Lu,Tianci Chu,Tianyi Wang,Daigui Cao,Fuyuan Li,Guangzhi Ning,Shiqing Feng
Frontiers in Microbiology. 2015; 5
[Pubmed] | [DOI]



 

Top
 
  Search
 
  
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  


    References
    Article Figures

 Article Access Statistics
    Viewed2563    
    Printed85    
    Emailed0    
    PDF Downloaded78    
    Comments [Add]    
    Cited by others 1    

Recommend this journal