Pulmonology Procedures |

A Novel Application of Endobronchial Ultrasound Guided Fine Needle Aspiration to Diagnose Lymphatic Cryptococcosis in HIV Positive Host FREE TO VIEW

Maria del Castillo*, MD; Ravindra Rajmane, MD; Edward Schenck, MD
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NYDH, Manhattan, NY

Chest. 2012;142(4_MeetingAbstracts):893A. doi:10.1378/chest.1390057
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SESSION TYPE: Bronchology Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Endoscopic Ultrasound Guided Fine Needle Aspiration (EBUS-FNA) has been increasingly used to assess non neoplastic lymphadenopathy. We present a case in which EBUS-FNA was successfully used to diagnose Lymphatic Cryptococcosis in a HIV positive patient. The lung is the portal entry and the initial site of infection for C. neoformans. It is usually manifested as multinodular pulmonary infiltrate or discreet crypotoccoma. Lymph nodes, and specifically thoracic lymph nodes can also be affected, but it is an uncommon presentation of disseminated Cryptococcosis.1 Pulmonary and extrapulmonary samples are essential to establish a definitive diagnosis that may be obtained by bronchoscopy, thoracentesis or fine needle aspiration (FNA).1 Moreover, lymph node FNA provides a economical and rapid procedure to cytologically diagnose this infection.2

CASE PRESENTATION: The patient is a 22-year old man with past medical history of HIV infection with a viral load of 12.000, unknown CD4 count and no antiretroviral therapy, presenting with headache and visual changes for 5 days. Lumbar puncture and blood cultures showed many Cryptococcus neoformans. Treatment with Amphotericin B, Flucytosine and steroids was started. The chest x-ray at admission showed a left mid lung cavitary lesion and left hilar opacity. CT chest showed a thick walled cavitary lesion located at the superior segment of the left lower lobe and a left hilar 1.4 cm lymphadenopathy. The cavitary lesion and the hilar lymphadenopathy failed to regress despite nearly 10 days of antifungal therapy. Since the patient continued to have fever and night sweats, bronchoscopy was performed to exclude other infectious processes. Broncholalveolar lavage and transbronchial biopsy did not reveal fungal elements, positive AFB smears or neoplasia. The diagnosis was made by EBUS FNA of the left hilium. Pathology showed numerous C. neoformans, confirmed by GMS and Mucicarmine stains.

DISCUSSION: Lymphatic Cryptococcosis is an uncommon presentation of the disseminated form of this infection. In this case, EBUS-FNA was used for sampling hilar lymphadenopathy. Cytopathology was obtained with adequate preservation of the tissue, allowing us to demonstrate the presence of Cryptococcus neoformans.

CONCLUSIONS: EBUS FNA has been increasingly able to provide reliable diagnosis in non neoplastic lesions. We propose EBUS-FNA should be routinely used in the assessment of suspected thoracic infectious lymphadenopathy.

1) Thomas G. Mitchell, John R. Perfect. Cryptococcosis in the Era of AIDS-100 years after the discovery of Cryptococcus neoformans. Clinical Microbiology Reviews. Oct 1995, p 515-548.

2) Garbyal RS, Basu D, Roy S, Kumar P. Cryptococcal Lymphadenitis: report of a case with FNA cytology. Acta Cytol. 2005 Jan-Feb;49(1):58-60.

DISCLOSURE: The following authors have nothing to disclose: Maria del Castillo, Ravindra Rajmane, Edward Schenck

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NYDH, Manhattan, NY




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