Hepatobiliary dysfunction as initial manifestation of disseminated cryptococcosis.

Disseminated cryptococcosis presenting as biliary obstruction is rare. We report a 35-year-old HIV-negative man who presented with clinical features suggestive of obstructive jaundice, and radiological features suggestive of Klatskin's tumor, but who ultimately was found to have cryptococcal involvement of the liver and biliary tract as part of disseminated cryptococcosis. The patient responded to antifungal therapy.     

Colitis as a manifestation of infliximab-associated disseminated cryptococcosis

The ability of tumor necrosis factor (TNF)-α inhibitors to impair pivotal pro-inflammatory host defenses may facilitate the development of disseminated cryptococcosis. Gastrointestinal (GI) tract disease is an unusual presentation of this yeast infection. We describe a unique case of disseminated cryptococcosis presenting as colitis that mimicked an exacerbation of Crohn's disease in a TNF-α inhibitor recipient. Review of existing literature shows that in immunocompromised patients, GI cryptococcosis invariably coexists with disseminated cryptococcosis, often lacks prominent GI symptomatology, and is primarily diagnosed postmortem. In cases with opportunistic infections, discontinuation of TNF-α inhibitors is a common practice, however rapid rebound of inflammatory responses may incur the risk of immune reconstitution syndrome.     

Pleural effusion as the initial manifestation of disseminated cryptococcosis in acquired immune deficiency syndrome. Diagnosis by pleural biopsy

Pleural effusion is an unusual presentation of cryptococcal infection in the acquired immune deficiency syndrome. Previous investigators have established the diagnosis of cryptococcal pleural disease by culturing pleural fluid, bronchial washings, and extrapulmonary sources. We report the first case of cryptococcal pleural effusion proved by closed pleural biopsy. Pleural biopsy may be an effective and rapid method of determining the etiology of pleural effusion in the acquired immune deficiency syndrome.     

Bowel infarction as the initial manifestation of disseminated aspergillosis.

Disseminated aspergillosis in the immunocompromised patient most commonly presents with clinically apparent pulmonary involvement and roentgenographic infiltrates. We report a patient with acute myelogenous leukemia who developed bowel infarction due to gastrointestinal invasion of Aspergillus fumigatus as the initial manifestation of widespread fungal disease.     

Cryptococcuria as a manifestation of disseminated cryptococcosis and isolated urinary tract infection

Fungal infection of the genitourinary system is a relatively uncommon presentation. Cryptococcuria has rarely been recognized in clinical practice. Patients with positive urine culture for Cryptococcus neoformans from 1992 to 2003 were retrospectively reviewed. Sixteen patients were identified. Nine (56%) patients were male, with a mean age of 44 +/- 21 (range, 16-88) years. Fifteen (94%) patients had underlying conditions such as HIV infection, diabetes mellitus, hypertension, and/or systemic lupus erythematosus. Thirteen (81%) patients had cryptococcuria as a manifestation of disseminated cryptococcosis, and the rest had only isolated cryptococcuria. Urinary analysis revealed proteinuria (75%), pyuria (31%), and budding yeast (13%). Nine (56%) patients received antifungal therapy. Other patients were misdiagnosed or died before treatment. The mortality rate was 64%. In conclusion, cryptococcuria is not extremely rare and can present as a manifestation of disseminated cryptococcosis or isolated urinary tract infection.     

Gonarthritis as only manifestation of chronic disseminated histoplasmosis

Summary A native from Surinam (South America), known to have a chronic gonarthritis for 20 years, died from an acute disseminated histoplasmosis. His gonarthritis was retrospectively shown to have been due to histoplasmosis. Although histoplasmosis rarely presents as a monarthritis, unacquaintance with this entity may result in fatal acute dissemination of the histoplasmosis.     

CMV sinusitis as the initial manifestation of AIDS

Summary Cytomegalovirus (CMV) disease is a typical late-stage complication of AIDS. Only six cases of CMV sinusitis have been reported in the literature. This is the first case of CMV sinusitis leading to the diagnosis of HIV and CMV retinitis. Diseases of the sinonasal tract may represent an initial manifestation of HIV or AIDS.     

Disseminated cryptococcosis with cutaneous manifestation

Cutaneous cryptococcosis is uncommon. It is usually a result of disseminated infection and can present with a wide variety of skin lesions. We report a case of disseminated cryptococcosis in a kidney transplant recipient who presented with nodular lesions in the forehead following a bout of acute cellular rejection.     

Achilles paratendonitis as the initial manifestation of rheumatoid arthritis

We report a case of rheumatoid arthritis in which the earliest symptom was bilateral paratendonitis of the Achilles tendons, followed by paratendonitis of a finger extensor. A series of musculoskeletal ultrasonograms revealed a progression from paratendonitis of the extensor tendon to erosive synovitis of the adjacent metacarpophalangeal joint. High-resolution ultrasonography combined with power Doppler imaging seems to be a useful and convenient tool both for diagnosing paratendonitis early and for closely monitoring the progressing inflammation.