Isolated biliary cryptococcosis manifesting as obstructive jaundice in an immunocompetent adult

Cryptococcosis is a symptomatic fungal infection caused by Cryptococcus, which frequently occurs in patients who are immunologically compromised or chronically ill. Localized involvement of the hepatobiliary system in an immunocompetent adult is extremely rare. We report a unique case of isolated biliary cryptococcosis manifesting as obstructive jaundice and mimicking hilar cholangiocarcinoma in an immunocompetent woman. By integrating surgical and antifungal drug therapy, the disease was effectively controlled. Despite an increasing incidence of biliary malignancies, hepatobiliary surgeons and gastroenterologists must maintain a high index of suspicion for other rare possibilities of non-specific biliary inflammation.     

原发肺隐球菌病误诊1例并文献复习

目的 提高对原发肺隐球菌病的认识和减少误诊.方法 报告1例原发肺隐球菌病的诊断治疗经过,并通过检索中国知网全文数据库,结合文献复习肺隐球菌病的临床特点和分析误诊原因.结果 本例病初按肺结核诊治2年,病情迁延反复,直至在痰液、支气管灌洗液和脑脊液中检测出新型隐球菌才确诊.经抗真菌治疗12个月,临床症状和体征消失,肺和脑部的病灶基本吸收.文献显示:①本病初诊误诊率高达56.5％(113/200),最常见的仍是肺结核,占49.6％(56/113);②仅9.5％(19/200)患者起病前有鸽类或家禽接触史;③临床和影像学的表现多样但缺乏特异性,无症状者占16.5％(33/200),无体征者占48.0％(96/200);④目前临床上确诊仍主要依靠肺组织病理、痰液或支气管肺泡灌洗液的病原学分离鉴定.结论 提高临床医师对原发肺隐球菌病的认识和警惕性,早期病原学、病理学检出病原体是减少误诊误治的关键.     

原发性肺隐球菌病14例临床分析

目的 通过分析肺隐球菌病(PC)病例,提高PC临床诊治水平.方法 回顾性分析14例PC患者的宿主因素、基础疾病、胸部CT表现、微生物检验、组织病理学检查、治疗和转归.结果 大部分PC患者有相关的宿主因素和基础疾病.胸部CT表现多样,多为单肺叶发病,以局限性多发混杂的结节和(或)肿块和(或)肺实变为主,此外还可见支气管充气征/小泡征、空洞、晕征等.支气管肺泡灌洗液真菌培养阳性率较低(18.2%),大部分隐球菌乳胶凝集试验阳性(64.3%),肺组织病理检查阳性率100%,氟康唑初始治疗有效(57.1%).结论 PC患者多有基础疾病,临床表现及胸部影像学表现无特异性,"晕征"为其相对特征性表现.隐球菌乳胶凝集试验无创,阳性率较高,确诊主要靠病理.氟康唑治疗效果好,不良反应小.

Abstract：

Objective To improve the diagnosis and treatment of primary pulmonary cryptococcosis (PC) by analysing the PC cases. Methods The host factors, underlying diseases, chest CT,microbiological and histopathological examination, treatment and prognosis of fourteen patients with PC retrospectively analyzed. Results Most patients with PC had related host factors and underlying diseases.The features of chest CT were diverse, mostly in single lung, mainly included local multiple nodules and (or) mass and (or) pulmonary consolidation, otherwise, air bronchogram / small bubble sign, cavity,halo sign were visible. The positive rate of fungal culture from the bronchoalveolar lavage was lower (18.2%) ,most of cryptococcus latex agglutination test was positive (64.3%), the positive rate of lung tissue pathology was 100% ,and the effective rate of fluconazole for initial treatment of PC was 57. 1%.Conclusions Most patients with PC have underlying diseases, clinical manifestations and chest imaging are nonspecific, and halo sign is relatively specific performance. Cryptococcus latex agglutination test is invasive, and the positive rate is high. The final diagnosis of PC mainly depends on pathology.Fluconazole is effective for the treatment of PC,and side effect is low.     

CT引导下经皮肺穿刺活检术对肺隐球菌病的诊断价值

目的探讨CT引导下经皮肺穿刺活检术（PCNB）对肺隐球菌病的诊断价值。方法回顾性分析本院PCNB诊断肺隐球菌病的4例患者病例资料,所有4例患者均行痰涂片检查、胸X线检查、肺CT检查及纤维支气管镜检查、CT引导下经肺穿刺活检术（PCNB）,检出物送病理检查。结果4例患者痰涂片、纤维支气管镜均为阴性,肺CT及胸X线表现为多发实变或结节状阴影。4例患者均经CT引导下行经肺穿刺活检术（PCNB）,榆出物送病理检查找到隐球菌而确诊。穿刺后无明显并发症。结论对临床难于确诊的肺隐球菌病,CT引导下PCNB是一种安全有效的诊断方法。     

AIDS-associated cryptococcosis: a comparison of epidemiology, clinical features and outcome in the pre- and post-HAART eras. Experience of a single centre in Italy

Objectives

To assess the prevalence, clinical and immunological characteristics, risk factors and survival of patients with AIDS‐related cryptococcosis in the era of highly active antiretroviral therapy (HAART).

Methods

All newly diagnosed cryptococcosis cases identified retrospectively from among a series of AIDS patients hospitalized consecutively at a single institution in Italy in 1985–1996 (pre‐HAART period, n=165) and 1997–2006 (post‐HAART period, n=40) were analysed comparatively.

Results

The prevalence of cryptococcosis decreased from 4.7% (165/3543) to 2.2% (40/1805) between the pre‐ and post‐HAART periods (P=0.0001). There were no differences in the clinical features or immunological status of the patients between the two cohorts. The variables associated with the occurrence of cryptococcosis in the post‐HAART era were older age (P<0.001), no previous diagnosis of HIV infection (P<0.001) and infection in homosexual males (P=0.004). During the post‐HAART period, immune reconstitution inflammatory syndrome associated with cryptococcosis was observed in five patients (19.3%) a median of 15 weeks after the start of HAART. Thirty‐day survival (P=0.045) and overall survival (P=0.0001) were significantly better among patients diagnosed with cryptococcosis in the post‐HAART compared to those diagnosed in the pre‐HAART era.

Conclusions

The AIDS‐associated cryptococcosis observed in Western countries in the HAART era has similar clinical and immunological characteristics to that observed in the pre‐HAART era, but a significantly better outcome.     

Recommendations for the treatment of fungal pneumonias

Incidences of fungal pneumonias have increased in immunocompromised patients with HIV infection or receiving bone marrow replacement or solid organ transplantation. Fungal pneumonias including aspergillosis, cryptococcosis, candidiasis, coccidioidomycosis, histoplasmosis and blastomycosis are one of the major causes of morbidity and mortality among the immunosuppressed hosts. Therefore, clinicians should consider the most appropriate and aggressive treatment of fungal pneumonias in this population. This report outlines the state of the art in the treatment of fungal pneumonias and discusses recent advances in antifungal therapy. Practice guidelines for the treatment with commonly used antifungal agents including amphotericin B, fluconazole, itraconazole, ketoconazole and flucytosine, are very useful for clinicians to manage the diseases appropriately. Echinocandins and second-generation triazoles will hopefully help clinicians to overcome the limitations of the current therapy.     

Spinal cryptococcoma in an immunocompetent cat

This report describes an unusual case of primary cryptococcoma in the proximal thoracic spinal cord of an 11-year-old immunocompetent cat from a farm on which there were large numbers of pigeons. This animal was referred for examination with progressive paralysis and shown to be free from feline immunodeficiency virus, feline leukaemia virus, feline coronavirus and Toxoplasma gondii. It died 2 months later. At necropsy, the only lesion detected was a malacic area, 4cm in length, in the spinal cord. Histopathological examination of the spinal cord revealed severe granulomatous inflammation associated with large numbers of encapsulated yeast cells. In addition to the granulomatous host response, necrosis, digestion chambers, Gitter cells, spheroids and lymphocytic perivascular cuffs were features of the malacic areas. Immunohistochemistry confirmed the presence of Cryptococcus neoformans var. grubii yeast cells.