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Volume 8, Issue 3 , Pages e28-e29, March 2010

Cryptococcal Gastroduodenitis: A Rare Location of the Disease

published online 15 October 2009.

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A 26-year-old woman originating from Zambia presented at the emergency room with a 3-week history of epigastric abdominal pain and biliary vomiting. She returned from Zambia 3 weeks earlier. She had complained of fever, and had been treated with an antimalaric drug which was stopped because of a negative blood smear. Epigastric pain was constant, not relieved by proton pump inhibitors, and accompanied by diarrhea. She had lost 10 kg in the last 3 months. Past medical history included pulmonary tuberculosis (2 years earlier) and human immunodeficiency virus (HIV) infection diagnosed 3 years earlier. Physical examination revealed an altered general condition, pale conjunctiva, oral candidosis, diffuse infracentimetric adenopathies, and epigastric tenderness. Laboratory exams gave the followings results: C-reactive protein 11 mg/L (normal range, 0–10); hemoglobin 85 g/L (normal range, 120–160); white blood cell count 2.2 × 10⁹/L (normal range, 4–11); platelets 125 × 10⁹/L (normal range, 150–350); CD4⁺ cell count 3/μL (normal range, 600–1950); HIV viral load 8.7 × 10⁴ copies/mL. Kidney and liver function tests were normal. Abdominal computerized tomography scan showed a thickened third part of the duodenum with an infiltrated mesentery as well as some free liquid between intestinal loops suggesting duodenitis (Figure A). Upper gastrointestinal endoscopy showed patchy lesions in the second duodenum suggestive of swollen, whitish villi (Figure B). Duodenal biopsies showed a slightly atrophic intestinal mucosa with a neutrophilic and eosinophilic polnuclear infiltrate within the lamina propria. Numerous circular bodies (arrows) were present in the lamina propria and in the submucosa at H&E coloration (Figure C). They were periodic acid–Schiff positive and the alcian blue coloration highlighted mucopolysaccharides surrounding the circular bodies (Figure D). The positive reaction of these inclusions at alcian blue staining, indicating mucopolysaccharides production, is considered to be highly suggestive of cryptococcal disease.¹ A few days later, the patient was diagnosed with meningitis along with a very high titer of cryptococcal antigen in the cerebrospinal fluid.

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In patients with HIV/acquired immunodeficiency syndrome, cryptococcus neoformans infection is frequent. The majority of patients initially have neurologic involvement (meningitis), and less frequently respiratory symptoms.² Gastrointestinal involvement is rarely described. Some cases have been individually reported but in the majority of them gastrointestinal symptoms occur secondarily in patients with meningitis.³ Symptomatic gastroduodenitis as the initial presentation of disseminated cryptococcosis is uncommon. This case underlines the fact that upper gastrointestinal symptoms in HIV/acquired immunodeficiency syndrome patients may be the initial presentation of disseminated cryptococcosis and that upper gastrointestinal endoscopy is an excellent way to diagnose it.

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References

Gazzoni AF, Severo CB, Barra MB, et al. Atypical micromorphology and uncommon location of cryptococcosis: a histopathologic study using special histochemical techniques (one case report). Mycopathologia. 2009;167:197–202
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Hajjeh RA, Conn LA, Stephens DS, et al. Cryptococcosis: population-based multistate active surveillance and risk factors in human immunodeficiency virus-infected persons (Cryptococcal Active Surveillance Group). J Infect Dis. 1999;179:449–454