P486 Disseminated Cryptococcosis diagnosed on fine needle aspiration cytology
Authors: Swain Satish , Gourav Sudesh , Pahuja Taruna , Singh Gagandeep , Xess Immaculata , Sethi Prayas 
Published: September 2022

Abstract

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM

Objectives (Case)
A 48-year-old male with no prior comorbidities presented to our infectious disease clinic with intermittent low-grade fever and gradual progressive swelling in his left axilla for 3 months. On further probing, the patient also gives a history of weight loss of around 7 kg. The patient belonged to a northern state of the Indian subcontinent and owned a grocery shop, where he worked. There was no recent or remote travel history, no history of exposure to animals or birds, no high-risk behavior, and no past or known contact history of tuberculosis. Still, in an endemic country like India and in this given clinical scenario, we kept tubercular lymphadenitis as the first differential and investigated the case further.

Methods (Investigation)
A contrast-enhanced computed tomography (CECT) of the chest and abdomen was done, showing multiple enlarged mediastinal and axillary lymph nodes with bilateral adrenal mass (Fig. 1). To further evaluate the etiology, a fine needle aspiration of the left axillary swelling was done. A hematoxylin and eosin (H and E) stain of the same showed the presence of numerous organisms of varying sizes present both intracellularly and extracellularly along with chronic inflammatory cells (Fig. 2a). Based on this picture, differentials of Histoplasma, Cryptococcus, or Toxoplasma were kept. But considering the empty spaces (halos) which probably represent the capsule and variability in the size, a strong possibility of Cryptococcus was kept. Serum cryptococcal antigen (latex agglutination) was negative but eventually, the fungal culture of the aspirated sample grew cream-colored, shiny dome-shaped, mucoid colonies on Sabouraud Dextrose Agar suggestive of Cryptococcus (Fig. 2b). The same was confirmed on Bird Seed Agar and Matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) mass spectrometry (MS). Gene Xpert of the aspirated sample was negative and serum cortisol with serum adrenocorticotropic hormone (ACTH) were under normal limits.

Results (Diagnosis)
A diagnosis of disseminated cryptococcosis was made based on the involvement of more than two non-contiguous sites (mediastinal with axillary lymph nodes and adrenal gland). The patient was initially started on liposomal Amphotericin B (5 mg/kg intravenous daily) with which he improved clinically. Same was continued for 2 weeks and later he was shifted to fluconazole 400 mg daily. As of now, the patient is on his 3rd month of fluconazole and doing well on follow-up.

Conclusion
Cryptococcus (Cryptococcus neoformans and Cryptococcus gattii) is an encapsulated yeast causing invasive fungal infection, with vast majority occurring in immunocompromised host1. It has a global distribution, predominantly involving the central nervous system (CNS) and lung. Management of non-CNS and non-pulmonary cryptococcosis is tricky as looking for dissemination is key (as the initial choice of agent varies)2. Adrenal involvement in Cryptococcosis is uncommon (as seen in our case). Examination of FNAC samples for Cryptococcus is also challenging as other microbes can also closely mimic the same. Finally, in a tuberculosis endemic country like India, clinical symptoms of Cryptococcal lymphadenitis can closely resemble tubercular lymphadenitis, so empirical therapy may be risky.
Figure 1 Axial CT Chest images showing multiple enlarged mediastinal lymph nodes (red arrow).
Figure 2a Fine needle aspiration cytology (FNAC) from the left axillary swelling stained with hematoxylin and eosin showing numerous organisms of varying size present both intracellularly (black arrow) and extracellularly with surrounding halos in a background chronic inflammatory cells.
Figure 2b Fine needle aspirate sample incubated at 37 0C on Sabouraud Dextrose Agar with gentamicin showing cream-colored, dome-shaped, shiny, mucoid colonies with smooth edge (characteristic of Cryptococcus).

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