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Communications to the Editor |

Mediastinal Lymphadenitis due To Cryptococcal Infection In HIV-Positive Patients On Highly Active Antiretroviral Therapy FREE TO VIEW

Massimiliano Lanzafame, MD; Marco Trevenzoli, MD; Giovanni Carretta, MD; Luca Lazzarini, MD; Sandro Vento, MD; Ercole Concia, MD
Author and Funding Information

University of Verona, Verona, Italy

Correspondence to: Sandro Vento, MD, Department of Infectious Diseases, University of Verona, via Locchi 12, 37124 Verona, Italy; e-mail: vento@borgotrento.univr.it



Chest. 1999;116(3):848-849. doi:10.1378/chest.116.3.848-a
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To the Editor:

Cryptococcus neoformans infection generally provokes meningitis in highly immunodepressed HIV-infected patients with very low CD4 cell counts (usually < 100/μL); cyptococcal lymphadenitis of cervical and axillary nodes has been reported in only one HIV-infected patient.1,2 We report two cases of mediastinal lymphadenitis in HIV-infected men treated with highly active antiretroviral therapy (HAART).

Case 1. A 33-year-old patient who had been HIV-infected since 1985, had cryptococcal meningitis in 1994 and was receiving fluconazole, 400 mg qd, since that time. After 6 months of HAART (zidovudine, lamivudine, and indinavir), in March 1997, he presented with fever, night sweats, and chest pain; the CD4 cells were 137/μL (13% of total lymphocytes), the CD4/CD8 ratio was 0.25, the HIV-RNA copies (Chiron Quantiplex assay; Chiron; Emeryville, CA) were < 500 copies/mL, and cryptococcal antigenemia (latex agglutination) was positive at a 1:16 dilution. The CT scan (Figure 1) showed upper mediastinal lymphadenitis, and histological examination of one lymph node revealed cryptococcal infection (Figure 2). The lymphadenitis resolved in 1 month without any change in fluconazole dosage.

Case 2. A 35-year-old patient had been HIV-infected since 1987, with no previous localization of cryptococcal infection. After 6 months of HAART (stavudine, lamivudine, and nelfinavir), in June 1998, he presented with fever and chest pain; The CD4 cells were 110/μL (10.5%), the CD4/CD8 ratio was 0.2, the HIV-RNA copies were 6,000/mL, and cryptococcal antigenemia was positive at a 1:2,048 dilution. The CT scan showed upper mediastinal lymphadenitis, and histology revealed cryptococcal infection. The cryptococcal antigen was not found in cerebrospi-nal fluid. The patient was treated with amphotericin B (Fungizone; Bristol Myers Squibb; Princeton, NJ) and symptoms disappeared in 3 weeks.

HAART has modified the natural history of several AIDS-related opportunistic disorders2 but did not seem thus far to have changed the clinical manifestations of the C neoformans infection, which are thought to be restricted to meningeal, pulmonary, or skin involvement. Our cases demonstrate that powerful (and, in one case, effective) antiretroviral therapy can be associated with highly unusual localizations of cryptococcal infection and that these infections can occur despite fluconazole secondary prophylaxis, even in patients with low antigenemia. Thus, chest pain in patients on HAART with fever may be due to cryptococcal mediastinal lymphadenitis, and if HAART is continued, careful monitoring for cryptococcal infection in patients with AIDS appears to be mandatory even when CD4 cells have regained levels > 100/μL.

Figure Jump LinkFigure 1. CT scan showing upper mediastinal lymphadenitis.Grahic Jump Location

Figure Jump LinkFigure 2. Multiple spores of C neoformans in the lymph nodal tissue (periodic acid-Schiff stain, original magnification ×1,000).Grahic Jump Location

References

Ginsburg, C, Aaron, L, Lesueur, A, Salmon-Ceron, D (1997) Lymph node cryptococcosis in an AIDS patient on long-term fluconazole: relapse or cure [letter]?Presse Med26,1049
 
Sepkowitz, KA Effect of HAART on natural history of AIDS-related opportunistic disorders.Lancet1998;351,228-230. [CrossRef]
 

Figures

Figure Jump LinkFigure 1. CT scan showing upper mediastinal lymphadenitis.Grahic Jump Location
Figure Jump LinkFigure 2. Multiple spores of C neoformans in the lymph nodal tissue (periodic acid-Schiff stain, original magnification ×1,000).Grahic Jump Location

Tables

References

Ginsburg, C, Aaron, L, Lesueur, A, Salmon-Ceron, D (1997) Lymph node cryptococcosis in an AIDS patient on long-term fluconazole: relapse or cure [letter]?Presse Med26,1049
 
Sepkowitz, KA Effect of HAART on natural history of AIDS-related opportunistic disorders.Lancet1998;351,228-230. [CrossRef]
 
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